Social distancing prevented Prav and Payman from being together in person this week, but it didn’t stop our hosts hearing from three true dentistry leaders.
In this fascinating roundtable, Prof. Nairn Wilson makes a welcome return to the show, joined by Dr Anthony Kilcoyne and Prof. Mike Lewis.
The trio discuss their predictions for dentistry in the post-COVID landscape and talk about what role the profession might play in the nation’s recovery.
“People have heard me lecture in the past, heard me say: “Why aren’t dentists used for things like winter flu vaccination and so on? We are properly trained healthcare professionals.” Better us than the army doing this testing. These poor guys in the army that are recruited into this, they don’t know one end of a swab from another…” – Prof. Nairn Wilson
Watch the video of the interview here:
In this bulletin:
00.00 – Notes on a crisis
23.39 – Meet the guests
25.39 – Post-lockdown kickstart
33.51 – Corridors of power – a view from inside
43.24 – COVID and oral hygiene – the link
01.08.58 – Psychology and SOPs
Connect with Prav and Payman:
Prav: So Pay, tell me how has lockdown been for you, Enlighten at home, things like that? Well, obviously we went through the mass panic, the hysteria, not knowing what to do and how things would settle down. Just talk me through the stages that you’ve been up to now, and obviously we’re going to be moving on to the interview where hopefully we’re going to get some of the answers of maybe what we should be doing and what the new normal will be in dentistry, buddy.
Payman: So look, for me, the first couple of weeks were kind of rabbit in headlights is the way I would describe it. So I didn’t know what to do and think. And at the same time I quite enjoyed being at home with the family. I’m enjoying being home with family right now, to tell you the truth. I think my life and your life are a bit different to most dentists lives. They have to be there at 9:00 AM. I know you get up at 4:00 AM anyway, but I was feeling guilty, Prav. I was feeling guilty that I didn’t have solutions to the problems that we were having. And it started off with the team at Enlighten. We met together and said, “Look, sales are going to go to zero.” I think we kind of anticipated that a week or 10 days before the actual lockdown was actually put in place and the team were already working from home before lockdown started, but how are we going to fund it all? The furlough scheme came in place, helped us a little bit.
Payman: Currently we’ve got four people not furloughed, four people sort of running the life support of the business, and we’re considering how to unfurlough people a week at a time going forward. But what’s made me feel a lot better now is I’m kind of being kinder to myself and not feeling guilty on this subject. And as soon as I started feeling that way, I started to find some solutions. And I think for us, as a company where all of our customers are dentists, of course a lot of our customers are patients as well, but actually it’s a B2B2C business, it’s become clear that the health of the dental practise as a business is number one, and only when the dental practise is a viable business will they even consider cosmetic treatments.
Payman: And so we’re planning now how do we help our users, our regional centres get out of lockdown in a sort of obviously safe way, and that’s something we’re going to be discussing later, but in a way that the business is viable. And after that I think we’re going to see another month lag between practises actually opening and practises actually thinking about looking at our products. Although I think, lucky for us, bleaching is non-AGP, and my thesis on it in the end is that non-AGP treatments like bleaching, aligners, facial aesthetics are actually going to be the things that save practises from a financial standpoint. What about you, bud? You’ve partnered in what, six dental practises?
Prav: Yeah. But before we talk about the practises, bud, what you just said there, I remember speaking to you when you’d just come out of … and you had the conversation with your team, and you’d said to them, “Look, this is what’s going to happen.” And they all turned around to you and said, “Thank you,” right. And it was pre-furlough. You said to me you were going to reduce their wages, right?
Prav: And a lot of their friends and colleagues had been fired, laid off, whatever, right. And I remember you building up to that conversation. You were saying it’s such an emotional time. And for me, mate, it was the day that Boris Johnson made that statement, okay. I remember Bob, my copywriter, senior copywriter, knocks on my door and he goes, “Prav, there’s just been a statement. They recommend we work from home.” So I called everyone over and I said, “Listen guys, this is what we are going to do. Pack your computers up. Today’s our last day here. And we may not come back for three months, four months, six months, whatever it is, but I guarantee you, whatever happens from this point onwards, you will not need to worry about your salaries.” And for them, it was huge, right. For them, it was enormous. And for me, okay, it’s remortgage my house, take some cash out of the business, and they’re the team who got us where we were today, and they’re the team that’s going to help us grow in the future, right. So I felt I owed it to them.
Prav: In a similar way, Enlighten is a family. Every time I visit your office, it’s a family. It’s not a corporate business. You know what I mean? It’s a fun place to be and everyone feels like they’re at home. And so that’s what happened in the agency. And then look, moving forward to the practise, a week or two later, we’re having these conversations and then doing cashflow forecasts. Who do we furlough? Who do we keep on for normal tasks? And then having that conversation. I was trying to get through my head that people who have been furloughed, sit at home, do nothing, get paid 80%. People who are not being furloughed, getting paid 100% but working their socks off, yeah. I had to get my head around that. [crosstalk 00:05:44]. It’s hard to compete with that, right. But at the same time you’ve got to be grateful and thankful that we have government support. Yeah. I mean we can all sit here and pick holes in it.
Prav: So there was all the shock, the rabbit in the headlights, the massive loss of income, yeah. And then everything settles, three or four days pass, and I say to myself, “This is actually pretty good.” Falling in love with my family again, spending times with my girls. My youngest has a nap at one o’clock. I’ll go to her bedroom at two o’clock and she’s drenched in sweat, yeah. She’s been sleeping. And she wraps her arms around me and falls asleep again on my shoulder. Never experienced that before, ever. And if it wasn’t for COVID, I wouldn’t have done. So there’s so many little micro moments like that that I am grateful for and thankful for. And for me, got myself into a routine. I don’t wake up at 4:00 anymore. Wake up at 6:00. It’s a respectable time, yeah. Get in the gym. I’ve got dedicated time with my family. I’m in the office. We’re busier than ever, and the team are collaborating together.
Prav: At the same time, on the practise side of the business, there’s lots of battles and things that we’re struggling with, and some of them is when we go back, how we will go back, in what capacity we will go back. What about all those patients who’ve paid for half of their treatments and need finishing off with AGP? Yeah. And we’re booking patients in now for say mid May, and now ringing them up and moving them on until June, and we may need to move them on until July. And there’s that whole admin process, and those systems, and process, and protocols, and at the same time we’re still carrying on with marketing, so we’re putting content out there. It’s more education. It’s less offer based. It’s more about connecting video consultations, and just making sure that people out there who want our services tomorrow, I want to develop rapport with them today. I want to make a connection with them today, yeah. I don’t want to sell to them.
Payman: Yeah. In marketing speak it would be work on brand now. It’d be marketing rather than sales now.
Prav: And it’s not a traditional advert. It’s not, “Roll up. Roll up. Get your £1,000 off this in free whitening, this, that, and the other.” The message is more along the lines of, “Hey guys, as dental professionals, we’re locked in our homes. Unfortunately we’re not in a position to see you face to face. And you’re spending more time at home as well. Let’s connect. Have a video call. We think it’s a good idea. Why don’t we just … Why don’t we just allow you to learn about how we work, what we do and how we can help? And then in the future you might want to come in for a full mouth checkup.” The message is that simple, okay. And what’s really surprising is that there are lots of patients who are unaware that dental practises are closed. They’re definitely not scared of walking into a dental practise, and they want to rock and roll with treatment straight away. Even though we know we can’t fulfil that.
Payman: The thing is, dude, your practises are so content heavy that if I am a member of the public doing some research into implants, aligners, whitening, whatever it is, your practises seem to come up. And of course that’s because of all the marketing bits you’ve put in place before. So what I think is your practises are funnelling in the demand for that, and that’s why they’re such successful practises. But going forward, as doors open, as the unlock happens, will lots of patients, the majority of patients feel comfortable coming in? And the conversations I’m having with non-dentists is, “How do you feel about going to the dentist?” And without fail, most of them say they’d be nervous about going to the dentist. When I ask them why they don’t mention AGP. It’s not on their radar.
Prav: They don’t know what it is.
Payman: Yeah. Although, a couple of TV appearances later, they might be, but what they’re saying is just close proximity to another human. Because with social distancing, we’re getting used to just crossing the road when someone’s walking this way and so on.
Prav: Do you know where the first time social distancing impacted me?
Prav: Very first time it hit home for me what it was. I walked into your office.
Payman: Oh, that time.
Prav: Held my arms out, yeah. Because you’re a hugger, right. Okay. We normally give each other a big hug, yeah. And I held out, and you looked at me like, “No.” I was like, “For real?” And you were like, “Prav, I don’t think you realise how serious is this, buddy.”
Payman: I had relations come in from Iran, and obviously Iran was ahead of the curve because of the disease, and over there they were doing the elbow and the foot things. So that’s why. I’d seen them.
Prav: So that happened. The morning after I went to have coffee with my buddy Danny Watson, yeah. And so we had coffee in Starbucks the morning after, in Manchester. And I looked at him, he looked at me and goes, “Are we going to hug or what?” He said, “Yeah, fuck it,” yeah. And we gave a hug, right. And that was it. And at that time, I don’t think it had sunk in how serious everything was in the whole social distancing thing, right. But very rapidly it did scale up. So with patients now, with what’s in the press, with the governmental recommendations, I think you’re probably right, the general public confidence of stepping in anywhere where it’s not a utter necessity, for example a supermarket or something like that, is going to be-
Payman: Yeah, I think that’s one of the main challenges for the profession as a whole, because I was on a BDIA call and they were saying in Holland dental practises are now seen as vectors of disease. People feel like you go to dentists if you have to, but actually you wouldn’t go at all because that’s where you catch COVID. And we’ve got to avoid that scenario in the UK, otherwise we’ll get put back another few months. But the problem we’ve got is there seems to be a vacuum of advice, a vacuum of regulations. We don’t even know where to look. I mean, is it The Chief Dental Officer? Is it the GDC?
Prav: Definitely not Facebook, mate.
Payman: Exactly. Is it CQC? Is it looking at other countries? We’ve spoken, both of us, to colleagues in Germany and Sweden, where Germany is doing so well on the Coronavirus and the dentists never closed. And in fact in some of these countries they don’t even see the electric handpiece, electric motor handpiece as a aerosol generating procedure. And so I think we thought the best thing to do was to get some experts on, and see from their position where we are, and try and unpack. Okay, it’s a new virus. It’s a new situation. It’s a once in a hundred year situation. So we’re not expecting all the answers right now. But when the answers come, where are they going to come from? Will it be CDO, GDC, or CQC? And what will they rely on? Will they rely on evidence? Will they rely on scare mongering? What will they rely on? Will they look at the far East where they’ve had SARS and MERS before? And that’s really the question for me. Who are we waiting for? Is it regulatory or is it advisory?
Prav: And speaking to a lot of dentists now, and key concerns in my own practises as well is it all revolves around this huge amount of uncertainty. A lot of scaremongering, a lot of, I feel personally, unnecessary panic buying, right. Masks in volumes, yeah. Air filtration technology. Fogging machines. Extra oral suction machines, yeah.
Payman: I think they’re a good idea, but, but keep going.
Prav: But whether it’s a good idea or not, we’ve got no guidance at the moment, right. So average practise goes out, blows 10 grand on all this stuff. Guidance comes out and goes, “Listen, just stick a visor on, make sure you follow these cleaning protocols, and you’re good to go.” So then what happens? Does that end up becoming a USP in a private practise? “Hey, I’ve got an air filtration system.”
Payman: I think that would be a shame if that happens, in my opinion. I saw a webinar with Miguel Stanley, and he said patients are going to seek out safe dentists, but I think it would be a shame if the communications message was, “Look at our practise, we’re safe,” because I don’t think overall that’ll work. That itself will go in the heads of the patient as practises are unsafe.
Prav: Unsafe. You’re not going to win that war, right.
Payman: Yeah. For me. I think that’s the case. I can’t be sure exactly how it will pan out, but the best thing for me would be if there was some basic guidelines that everyone had to stick to that work-
Prav: They’re discretionary extras.
Payman: Exactly. Nice to haves. But then I don’t think it’s wise to market my practise is safer than the practise down the road because I think that makes you look unsafe by itself. [crosstalk] were Dominic’s, I thought. Dominic’s piece that he wrote about aerosol, Dominic O’Hooley, and Tony Kilcoyne wrote a lovely piece 10 years ago. I don’t know if you read that. Did you read that?
Prav: I haven’t read that.
Payman: 10 years ago he wrote a piece about, “Look, why do we only clean the surgery? Why don’t we clean the waiting room? Why don’t we clean doorhandles? Why are there toys everywhere with cross infection on those?” Some simple basics.
Prav: Yeah. I read Dominic’s, and it really sort of got me thinking.
Payman: He does. Brilliant writer.
Prav: Because do you know what? When you consider all the hysteria on Facebook, the panic buying, the what ifs, the buts, the SOPs, all this, right. And then you look at the science, and I’m a scientist at heart. So you look at the science, you look at the evidence, and I reached out to Dominic and actually said thank you because I think he’s done something really good for the community in spending the time. He’s definitely got something up here, and the energy to be able to dig into this research and then put it down in a way that’s very easy for all of us to digest, right.
Payman: Well, one word of caution, Prav, though. It’s been banded about quite a lot, there is no evidence to suggest, yeah. Under normal circumstances that would mean something, but in this situation, I think we do need to be aware that it’s so new that there isn’t much research, and just because there is no evidence doesn’t necessarily mean it’s not true yet.
Prav: I get that. And no evidence doesn’t mean that hey, we’re totally safe, right. But if I’m looking at things from a very, very simplistic perspective, right, and scientific, but not super scientific, right. And say right, okay. There’s some water firing down these lines and it’s got hypochlorous in it. And it hits the mouth, and then some of it bounces back out, and 99% of it goes down a massive vacuum cleaner, and 1% of it comes out as an aerosol. And it’s incredibly dilute, yeah. I think everything that we do involves taking a risk, mate. Walking out your front door, getting on a bike, jumping in your car. And I think we need some guidance on what that risk versus benefit things should be, okay. Because there becomes a point where you’ve got diminishing returns, yeah.
Prav: You can add on layers and layers and layers and layers of protection, and then the decontam room, the fogging, the this, the that, 20 minutes between, 30 minutes I’ve heard, between patients. What’s the implications on patients actually getting healthy mouths again? What’s the financial impact on the businesses? Let’s not skirt around the financial issues, right. We can always say, “Oh yeah, dentists agreed,” and all the rest of it, but we’ve got businesses to run, okay.
Payman: Yeah, I mean it sounds like 30% are in trouble.
Prav: We’ve got jobs to maintain, okay. And people’s livelihoods, and putting food on the table for our team members, yeah. And so we do have to look at the commercial side of things. All this extra PPE, laser protection, I think it adds time, it adds expense. Who’s going to pay for this? Is it going to be the government? Are we going to do it? Are the associates going to pay for it? Are the principals going to pay for it? This has got to come from somewhere, right. I really, really hope that the three guys who we’ve got on today have the answers to the key questions, which are who’s going to make that decision for us? What does comeback mean? Yeah. In what capacity? And when will it all end? Are we going to be in a position where this is the new normal, or is it a new temporary normal and then we go back to normal?
Payman: Yeah. I think [inaudible] the latter, I think the latter. We won’t know for sure. It’s going to be phased. The guys we’ve got on, they’ve got years of experience, both in the research side and what I would term as the corridors of power. Maybe they’ll shed light on it. We’ve got to be aware though, dude, it’s once every hundred years. So no-one’s been in this particular situation before. We did have SARS, we did have MERS, we did have HIV. So I’m looking forward to it.
Prav: Absolutely. Let me ask you one final question, mate. Obviously your wife’s a dentist. How does she feel about going back to work?
Payman: My wife’s a at risk dentist, so it’s a layered thing, but she’s quite relaxed about it, strangely enough. Quite relaxed about it. I think she’s thinking … She works at Bupa. I think she’s thinking that Bupa will take care of it. But-
Payman: … but we’ll take care of it, but it’s one of those things. Your brother’s a dentist.
Payman: Your brother’s a dentist. So, this affects everyone. The thing about it is even if you are not a dentist, even if you’re not in contact with people, you’ve got a grandparent and on the global perspective, if any good comes out of this, there might be some feeling of whatever’s happening in a rich country, we’ve got to look up for the poor countries too because infected people will be infected people. For me, if we’re really zooming out, it’s a disgrace that there’s bio weapons labs, what’s that about? Is it ever going to make sense to attack another country with a germ warfare? If it does make sense that’s not a future I want to be part of that would be great. Just like some of the other silver linings, that the environment is cleaning up.
Prav: Amazing, yeah. Yeah.
Payman: I think tele dentistry, virtual …
Payman: Virtual consultations should be something that continued forever because why not? Why shouldn’t someone triage that patient before they come in and you book them a 40 minute appointment, really it should have been 10 minutes or whatever it is. For me, and I want to put this to the guests as well, the NHS, the way it was, 40 patients a day, is it possible to clean up between 40 patients a day properly? And then is it possible to treat those patients with work that’s going to last and isn’t going to come back and haunt the NHS again? For me it would be nice if, if that volume dentistry again, Miguel talks about slow dentistry, but we’ve all known about it. If anyone’s ever been exposed to NHS dentistry, they know about it. It would be good if after this there’d be some sort of impetus to improve the NHS, put more money in, or call it a core service and people save up for their teeth. Yeah, that’s the one thing I’m going to ask them.
Prav: Cool. Let’s get the boys on.
Payman: Let’s get it on.
Intro Voice: This is Dental Leaders, the podcast where you get to go one on one with emerging leaders in dentistry. Your hosts, Payman Langroudi and Prav Solanki.
Payman: Welcome guys to the first of the Dental Leader’s Bulletin. This little meeting that we’ve organised today is to look at the situation that we’re in right now and to try and put some light on, some of the unknowns that the profession is going through right now. I mean obviously with the new virus, it’s difficult to get the full story, but we’ve got a panel of experts with us. We’ll start with Professor Nairn Wilson, who’s served as the Dean of both Manchester and the Kings Dental Schools. He served as the president of the GDC, the BDA, developed visible light curing. We could keep going, but right now prof, you’re actually founding the College of General Dentistry soon to be hopefully the Royal College of General Dentistry.
Nairn Wilson: Absolutely right, and I’m here today as capacity as chair of the college, thank you.
Payman: Perfect. We’ve got Tony Kilcoyne who has served in many roles. He’s served on the GDC twice. He served at the BDA. He’s currently serving at the BDA. He’s been trainer of the FD, he’s the director of training of FDs for over 30 years now and has been an examiner at the Royal College of Surgeons. Although Tony’s speaking independently today as one of us, one of the front line. Nice to have you, Tony.
Anthony Kilcoyn…: Thank you.
Payman: And we’ve got professor Mike Lewis who’s professor of oral medicine at Cardiff, past Dean of Cardiff and has served as the president of the British Society of Oral medicine, president of the British Society of Oral and Dental Research, currently on at Cardiff Dental School. Is that right, Mike?
Mike Lewis: Yeah, yeah. I’m sorry, you broke up a little bit there, but yeah, Cardiff Dental School, professor of oral medicine.
Payman: So I think we want to unpack the situation a little bit and I think the first thing we want to start with is we know that the exit out of lockdown is going to be phased. That’s one thing we know. What should those phases look like and who makes the decisions. Let’s start with what those phases should look like. Should we start with Nairn, Professor Wilson?
Nairn Wilson: Well I think as you’ve indicated, I think it’s got to be phased, I think has got to carry the confidence of the public, the patients we treat. They don’t want a run of … As hospitals and GPS are saying, people frightened to go and speak to them. We’ve got to bring them back and gain their confidence, in the different levels of phase that we move in, we’ve got to be a safe environment for all the members of the dental team within the practises. They’ve got to feel safe coming to work, et cetera. But of course we’ve got to be safe, our colleagues who are in practise have got to be safe for the sake of themselves and their own families and so on. So I think safety, trust and an evidence-based approach to getting back to it, I think is what we’ve got to do.
Nairn Wilson: I think it will be step by step. Clearly we’ll have priorities of extending emergency dental care services so people don’t have to travel big distances to dental care centres, et cetera. Then rolling that out as a system of priorities, maybe kids, elderly people, et cetera, et cetera. That sort of approach very much I think is the sort of thing that we’re going to hear of how the country’s going to get out of lockdown. I think it will mirror that a little bit, but it will be prioritised in my view in moving forward. I don’t know what the other folks think.
Payman: Tony, what do you think?
Anthony Kilcoyn…: It’s interesting isn’t it? Because I think there is two aspects to this. There’s very much the psychological aspect. You want the confidence of the public. Even our teams going back are going to be a little bit unsure and of course then on a individual patient dentist relationship, coupled with we have a mountain of pent up dental need. Bear in mind now, we’re entering the second month of basically loads of people having dental problems not being attended to. The three As approach. I mean come on, it’s a bit desperate isn’t it, really? Because dentistry nine times out of 10 or more, needs an actual direct intervention to improve matters. That is the nature of our job. It’s very hands-on. So we’ve been putting things off with painkillers, advice, antibiotics, but those problems haven’t gone away. There’ll be very few things that will have been fixed by any of that. So there’s actually a tsunami of need.
Anthony Kilcoyn…: So the idea of a phase back fits in nicely with the psychology of it. Let’s dip our toes in the water. Oh great. We didn’t all fall off our perches straight away. Let’s do a bit more expansive scope. Oh great, we all survive that. Then psychologically we can get back to almost normal operative dentistry because let’s face it, without high speeds and ultrasonics and all the rest, we’re not actually doing more than 50% of the routine dentistry and the substitutes for it aren’t that great. It’s a bit like the triple A approach is not a great substitute for dentistry generally. So I think the phases are more psychological than what the science would say because if you put certain risk reduction approaches in place, and I think the history has shown that dentistry is actually a relatively low risk environment.
Anthony Kilcoyn…: If you put certain risk reduction processes in place, I personally don’t see why and the evidence base is just generally weak is our problem, but I personally don’t see why we can’t make those phases go a little bit more rapidly than some of the reports I’ve been hearing generally of, we won’t be back to normal dentistry by the end of the year. I’m sat here thinking, well why not? What’s the evidence for not doing that? But I think there are some psychological barriers to overcome first. We will have to look at how we do risk assessments and how we chase some approaches. Not because dentistry is dangerous, but because psychologically the general population, we’re in unprecedented times. We’ve had a lockdown in society. I don’t remember that happening in my working lifetime of over 35 years.
Anthony Kilcoyn…: So this is being taken seriously. We have to be seen to be taking it seriously. So I think the phase in is more psychological steps than it actually is, well the evidence says that’s all it’s safe to do because I don’t think the evidence says much at all.
Payman: Do you think it’s going to be emergencies only or none GP only?
Anthony Kilcoyn…: People are going to argue about where are the lines drawn. I would argue that you have to look at the risk assessment and probably look at it from three points of view. Your staff, first of all, I mean some of those might already be suffering or having infections, who’s able to work who isn’t, who’s recovered and already relatively immune to the disease. That could change the way we approach how we treat patients. So we have to actually assess, literally risk assess, what are staff are like, what’s our environment like, and what’s the patient attitude like?
Anthony Kilcoyn…: I know some areas you could say, “Yeah we’re doing everything,” and there’d be a queue out the door. You could just say, “We’re seeing emergencies.” There’s still going to be a queue out the door because we have this pent up need that’s there. So I think almost just logistically as well, you’re going to have to look at how about pent up need can best be managed because it will have to be managed, where … It’s a bit like the R number in reverse. We need to get through more than one patient to fix them before another patient gets worse. We need to get two in before one gets worse so that gradually, we start reducing this mountain of built-up dental need. Because for a while we’ve been saying dental disease affects your general health too and if people are walking around with more infections and all those toxins going into their own systems and so on, that’s not good for their general health either. So for society, we’ve had to make this work.
Prav: One of the questions on my mind that I, being a practise owner as well as speaking to a lot of practise owners and the uncertainty about not only when do we go back but Payman, you mentioned this phased approach and let’s just stick to say phase one. What does that look like? Because some practises are putting together SOPs that involve fogging the surgery, cleaning it down, 20 minutes decontamination, patient waiting in the car park, et cetera, et cetera, and there’s a complete lack of guidance or certainty in terms of what’s the right thing to do, a lot of confusion people putting together these SOPs and as a practise owner, part of me’s thinking, how are you going to get through the NHS waiting list if you’re mopping down for 20 minutes in between patients? Who’s going to be the person who actually decides this is the protocol? Or is that going to be at our discretion as practise owners or is there going to be a minimum guideline set? What is that? Who will decide? Will it be different for NHS or private?
Prav: Quite a few questions there that have stemmed off phase one but I think when I’m speaking to practise owners and my principles, it’s this uncertainty of phase one, what is it? Prof Lewis, you mentioned that … the air filtration systems, for example. Will that be mandatory in practise or will it be a nice to have, for example?
Mike Lewis: Right. Yeah, and I think you know, I agree with Tony and what Tony was saying. I mean, I think underlying this we have to get dentistry back on the road. I think we are all striving to get that. It’s frustrating me with my patients here that these clinics are all closed. But to do it in a way that we’re comfortable, we feel safe, our staff feel safe and the patients feel safe, again as Tony said, I think you have to accept that dentistry really is got the rough end of the stick here because of the aerosol generation and the fact that COVID is in saliva. If you generate a saliva, there is no doubt we haven’t measured loads yet, but it has been shown that it’s in saliva. So for non-aerosol generating procedures, that’s what I’m doing here at the moment.
Mike Lewis: I spent a day yesterday, I saw about 20 patients yesterday with toothaches that needed … perhaps they needed some extractions. I saw an urgent suspected cancer that needed a biopsy done. I did that biopsy with just routine mask, visor without, FFP3 regulations and I had no problem with that. We’re washing down the units in the same way as we would as every day, pre-COVID. So I think for certainly for the non …. Phase one would certainly be let’s get back, non-aerosol generating procedures. Let’s get the patients back in. If we do say that … I think the air clean systems aren’t going to be the way forward. I remember and Nairn will certainly remember, we used to clean our instruments between patients in a hot water bath at the end of the comms clinic in dental school and then we got these things called autoclaves and then we actually started wearing gloves.
Mike Lewis: I mean that was a miraculous … I remember all the things. It’s all about, “We’ve got to wear gloves and do we wear the same gloves all the time?” And then of course, prions popped along a now we’ve got to have washer/disinfectors. I mean this is just the next stage, that the issue of viruses in saliva, it’s not been before. Herpes simplex has been documented at spreading from saliva into nurse’s eyes and hepatitis B can be spread from saliva into the eye as well. So the aerosol issue has to be addressed and I think we can reassure ourselves and address it with high volume aspiration. The video clips that were shown on the television didn’t really quite explain what happened but there were two there and one of them was with the use of high-speed volume aspiration dramatically reduces the aerosol, it’s taking it down 99%. then if you had an air clean system in the surgery as well, that will take the rest out. These air clean systems are very effective.
Mike Lewis: Whilst we did the research 10 years ago, we were looking at bacterial spread, the filters that can be put in these air clean systems, will take COVID out and all sorts of other things that we may be worried about, particles in the environment. Because the latest research from two weeks ago where they were looking aerosol generation, the virus will float around in the room for about three hours. But if you’ve got an air cleaning system, it’ll take that right down.
Mike Lewis: So we, I think as dentists, would be more confident where we’ve got this environment. The support staff would be more confident and then hopefully the patients will be more confident. That is the realistic way of getting dentistry back on the road because we’ve got to do it. I’m frustrated here. We have a dental school sat empty and I feel for … The final year students fortunately have done most of their practical work, but the ones that are coming in for fourth year into final year, we’ve got postgraduate students paying large sums to be learning dentistry, hands-on techniques. They’ve paid us money, we’re not delivering it. It’s an awful situation but I think with common sense and us all working together, then we’ll beat this.
Nairn Wilson: One of the things, I know I’m not personally involved, but standing back and looking at it. I think one of the great sadnesses to me is that the current system has not taken opportunity of all that dentistry could offer. For example, why aren’t dentist practises being used for virus testing centres? 20 odd thousand around the country, good access and local communities. Get dentists, well-trained health care professionals who know about infection control. Give something dentists to do, give them some money coming into the practises and if then, through using those practises as testing centres, A, the dental team are tested maybe once a week. I know it’s not every day, but at least once a week and the patients who come for testing, you know that if they’ve got a problem that they need to be [inaudible 00:18:05]. You’re saying, “Well, you’ve got a negative test, we could see you, we can do something. I’m negative, you’re negative. We could start.”
Nairn Wilson: To me, a way of kick-starting dentistry back in would be let’s use dentistry. People have heard me lecture in the past, heard me say, why aren’t dentists use for things like winter flu vaccination and so on. We are properly trained healthcare professionals better us than the army doing this testing. These poor guys in the army that are recruited into this, they don’t know one end of a swab from another, sort of thing. We [inaudible] and our healthcare professionals taking these samples at back of a throat, I think we might be quite good at that. That might’ve been a way in.
Mike Lewis: Can I just come and say Nairn, I think that is absolutely fantastic because I don’t know if you saw on the news last night they were talking about the self home kits and they show the person where they’re supposed to stick the swab. We know where to stick our swabs. There is no doubt about that and I think this suggestion is fantastic.
Nairn Wilson: It’s going back to what Tony was saying, what I was saying about building that, getting that relationship back with the patients, trust. “I came to you, you’re the guy, or person, lady who tested me, kindly just down the street. You reassured me I don’t have the disease, et cetera.” That’s breaking that psychological link again and getting them back in a practise and building that trust and giving everybody trust. We’re only treating people who have tested negative in the last three, four or five days or whatever and we’re all tested negative and wouldn’t that be good that if we’re helping to pick up people who are carriers who’ve got the disease and of course in the process, as Tony was saying, our link with general health and so on, we’re going to say, “How are you?”
Nairn Wilson: These people aren’t going to their doctors about heart attacks, strokes, cancers, lumps and bumps. A good dentist with good communication. “How are you doing Mrs. Smith?” Or, “Well I’ve been a bit anxious the last week or two. I’m breathless, I’ve had chest pain.” We could pick that up and get these people back to hospitals and so on. We’re good at it and we’re not being used and I think it’s a great shame that dentists and the facilities and the potential is there. It’s just not in the minds of the folks that are firefighting this terrible situation the country finds herself in. I wish somebody would wake up and say, “Here’s a wonderful resource. Let’s use it.”
Payman: Nairn, you’ve been in the corridors of power. Who makes these decisions?
Nairn Wilson: Well, as you see, it’s the advisors to the government to et cetera, but with no disrespect, they’re all medics and so on. We’re probably just not in their thinking. We’re not on their radars.
Nairn Wilson: And we’re probably just not in their thinking. We’re not on their radar screen. They don’t appreciate… And even, again with no disrespect to them, some very senior people in medicine, who think that dentists are just filling and taking teeth out, don’t really appreciate that the extent of our training and appreciation of human disease and looking at people holistically.
Nairn Wilson: And it is sad in this day and age that there is this lack of appreciation of what we can contribute, as Tony was saying, to general health and wellbeing. And this, to me, is an example that we could do this and we could make a huge contribution. They’re very much in the thinking of the College of General Dentistry of getting this brick in this dome. We are part of healthcare system in the UK. We are important.
Nairn Wilson: And other issues are missing at the minute. I know it’s the immediate topic today, but why aren’t people being encouraged to brush their teeth and use mouthwash before they go out in the street? Possibly more important than some face covering, or equally because there’s not much evidence, we keep getting told that it’s not much a benefit. Maybe brushing your teeth and using a mouthwash before you go to the supermarket, or whatever.
Mike Lewis: If I can come in there, the ITV have just asked me to put out a press release following on from what I was saying on the TV early in the week. There is no doubt I have a mantra. Wash your hands, clean your teeth. And the basis behind that is that there is no doubt that from the work that we did here and published in Critical Care about four years ago, we were looking at oral hygiene in relation to ventilator patients.
Mike Lewis: And we demonstrated without any doubt that if you go into… Say you’re COVID, you go in and you have to have a ventilator, your chances of coming out of there alive will be related to your oral hygiene. Now that’s on the basis of going in and of course maintaining oral hygiene when you’re ventilated is difficult. And we did studies using brushes and swabs, and everything.
Mike Lewis: I don’t want to complicate it too much about that, but there’s the benefits of good oral hygiene at this stage. If you were unfortunate enough to get COVID-19 and then be unfortunate enough to require ventilation, the better that your oral hygiene when you go into there, the greater the likelihood of coming out and there is no doubt about that. We publish these papers three or four years ago on a molecular basis.
Mike Lewis: What I do agree with you right now is that if it’s a great opportunity to get people brushing their mouth. And I said the four… You’re all in lockdown. The four most important minutes of your day today are two minutes brushing your teeth this morning and two minutes brushing your teeth this evening. And when I said that on the TV, the newsreader actually laughed a little bit, because it’s true.
Mike Lewis: That should be the message out there. The foremost important, because not only is that going to be good at hopefully preventing if you are unfortunate to become COVID-19 positive, but it’s going to get people brushing their teeth anyway. And for the benefits of the dental need out there, that we’ve been trying to get them to brush their teeth for two minutes twice a day for, I don’t know, as long as all of us have been in the profession and it doesn’t work.
Mike Lewis: This message out there is brush your teeth. We are now in a fantastic opportunity. Now there’s a little bit of evidence that Martin Addy I understand published in the BDJ, had a letter in the BDJ two issues ago. And I think the press have picked up on that and they’re going to interview him this weekend about some of the active ingredients in toothpastes, because some of the components of toothpastes actually have… They’re the same as they are in hand sanitizers.
Mike Lewis: Now if you teach it… And the way I teach virology is you imagine it as a little scotch egg and the scotch egg is… The COVID-19 is the egg inside. It’s an RNA virus. The crumbling coating on the outside will determine which cells that virus gets in. Now in COVID-19 it’s cells in your lungs. So, it allows it to get into the lung. If you disrupt that coating, it can’t get into the lung. It cannot get in.
Mike Lewis: So, anything within… If there’s saliva in the mouth or the throat, brushing is good, but also using a toothbrush, or some of them. The Listerine mouthwashes, the essential oil mouthwashes, povidone-iodine. Chlorhexadine not so much, because it only has an anti-adherence effect, but I have to pick up on what you said there and the ITV are coming back to me. They’re doing some national meeting at the moment. They’re going to ring me back later today, but I’m hoping that the dental profession out there is… And I’ve altered my email signature. Wash your hands, brush your teeth.
Nairn Wilson: Sorry, very quickly. I’ll come and… We haven’t heard from Tony. He’s being uncharacteristically quiet there. But a little bit of dental history, they say it’s nothing new and our medical colleagues… Again, notice, right? The same problem there. In the first world war where they had to operate on people with ether and its inhalation. If, as was very common, they had trench mouth, i.e. acute ulcerative gingivitis, or whatever its new term these days. I do get confused.
Nairn Wilson: The perio people keep changing the terminology, but it was well known then that given your mouth’s such a bad condition, if we give you an anaesthetic, it’ll probably kill you. So, maybe we’ll operate without the anaesthetic and you might survive. Now that was in the first world war. Same message, yeah? And our medical colleagues who given a hundred years that this sort of stuff has been appreciated, it hasn’t twigged on them. And when they’re giving all… Mike is saying they’re showing all these pictures of people coughing and sneezing and so on. Where’s it coming from? At least half of it’s coming out at the mouth, yeah?
Narin Wilson: Tony, what’s your experience? Okay, we’re saying central government medics don’t appreciate where we’re at, but once it filters down to dentistry, is it the chief dental office, is it the GDC, is it CQC? Who’s going to regulate, or is it down to the professionalism of the dentists themselves going forward?
Anthony Kilcoyn…: I think my other two colleagues on this forum today have made an excellent point that generally dentistry is being undervalued and it’s probably due to a lack of wider knowledge. Even in our medical colleagues, but also regulators, politicians, the people with power. They really can only relate to their own personal experience of dentistry. When I speak to them, lobby them, as do many of my other colleagues, they’ll often quickly refer to their personal experience with their dentist.
Anthony Kilcoyn…: So, that’s very important. Don’t get me wrong. That is very important, but their relative breadth and depth of knowledge of dentistry is not good, and that’s being subtle. Unless it becomes a news story, or a disaster, or a problem, and then they look at it and it becomes an irritation and an annoyance. And for so long I feel like we’ve been the Cinderella of all the health care sector. I think the only other healthcare sector that’s probably treated even worse than us is mental health. Well, after that it’s us. It’s dentistry.
Anthony Kilcoyn…: We’re highly skilled, we’re highly trained, we do five years at university, and all the other additional skills. Narin said the point of we have a bigger role to play in society as diagnosticians and interpreting the results and doing it well. We’ve got a big role in improving oral health to improve general health, and we can monitor and interpret that.
Anthony Kilcoyn…: We do medical histories on everyone all the time. Our quality of PPE and routinely changing things between patients. I don’t know about you guys, but I laugh sometimes when the show a TV clip of the medics struggling and they almost need that second person to remind them what to do in more order, because they’re doing something out of the ordinary. We’re looking and thinking, “Well, it’s obvious how to put a mask on and take it off, and not touch the front and not contaminate it.”
Anthony Kilcoyn…: We do this between every single patient. That’s our normal. We are very good at this and that’s I think is actually what has protected us for so long. But the appreciation of what we can do and what we do for society is very poor in many levels of politics, regulation and even in all these advisory bodies at the moment. Going into SAGE, how many dentally qualified people are on SAGE? NERVTAG, who then feed into that, and then when they do all that evidence about PPE and saying, “Oh, you can wear the mask for a full session.”
Anthony Kilcoyn…: We’re all scratching our heads thinking, “Well, hang on a minute. That’s even worse than what we were doing before. We were changing everything between patients.” And I drill down all their evidences and papers, and there’s about 19 papers. They’ve lumped us in with all the medics again, but there’s only two specific papers there that are dentally related.
Anthony Kilcoyn…: And one’s from 2011 and one’s from 2006, and you sat there thinking, “Oh, my God, they’re talking about this wonderful NERVTAG panel they’re feeding into SAGE, they’re feeding into COBRA, they’re feeding into the politicians.” And you sat there thinking, “Basically they’re using two out of date references that sort of semi-related to dentistry and they have no idea what’s happening on the front lines.”
Anthony Kilcoyn…: You ask the CQC who is the best healthcare performer of all the healthcare sectors that they regulate, who’s the best? Number one by a mile: dentistry. In fact, they were surprised that why is dentistry been added to our list to inspect? When they went around the practises and saw what happened, and saw how intrinsically patient centred we are, they were scratching their heads thinking, “Why have we got dentistry?”
Anthony Kilcoyn…: We’re in the top 90 odd percent performers. We’re so good. They’re actually saying on average we only need to visit you once every 10 years. Everywhere else, the hospitals, or the medical clinics, they’re in the 80%. They’re struggling. The poor care homes at the moment, they’re far higher risk and don’t have the same cross infection control and what I would call a closed circuit environment that we control so well, and have been patient focused for decades.
Anthony Kilcoyn…: This is not new to us. This is our bread and butter. And we are very, very not just unappreciated, but nobody realises actually just what high standards we have routinely. So, this is when people talk about after lockdown and going back, and so on. I don’t think we’re a million miles away at all. I think medicine might be. I think the way we visit people in hospitals and wards, and the free flow of vectors with different patients and hospital acquired infections.
Anthony Kilcoyn…: Somewhere between 4000 and 8000 people die a year from a hospital acquired infection. They went in with something and ended up catching something else and it killed them. So, we just don’t have that in dentistry, because we’re so well controlled. It’s our closed environment. Okay, patients are there for a relatively short time and they’re not residential overnight, but we’re already in tight control of that. So, when Mike says stuff about the aerosols and so on and reducing it, we’ve been using high volume suction for a long time.
Anthony Kilcoyn…: In fact, as I go around and inspect practises, we’re all supposed to have extractor fans in the room. Now it goes through different phases of how important that is, but even health and safety executive will tell you that there’s a minimum of air change that has to happen every hour. But if you look at the latest guidance coming out about these high filtration units now, they’re talking about if you have six room changes of air in an hour, then you need to leave an hour between patients to be a hundred percent sure there’s no aerosol there.
Anthony Kilcoyn…: But if you have 12 changes in hour, you can leave 30 minutes. And, of course, everyone’s going, “Well, I don’t know what my fan does.” So, I had to go back and look at mine. Mine does 15 an hour, but that’s the 12 inch Xpelair super duper one, because I remember putting it in and thinking, “Well, if you’re cutting up through all through my glass, we might as well pay another 50 quid and have the better fan on, because I’m doing it once kind of thing.”
Anthony Kilcoyn…: So, who knows? So, of course, we need some at near the mouth and so on, but what I’m saying is we already have a lot of these risk reduction ideas in place. We might have to enhance in some way. We certainly are going to have to screen the patients better. We can’t have 40 people a day just coming and filling up the waiting rooms and being too close to each other at this time. So, we are going to have to streamline that, but I think with a few sensible risk reduction approaches and the phased approach, not because we’re high risk but because psychologically we just need to reassure patients first, nobody dies. Right, we can step up a gear and so on.
Mike Lewis: Right, can I just come in on that just to support Tony completely on that. Firstly with regard to washing your hands, PPE, et cetera. When we did infection control audits across this site, that’s not just the dental hospitals, but it’s the University Hospital of Wales, the biggest hospital in Wales. Dentistry always came out on top. Our house was in order. We were always up there in the high 90% for adherence to the hand washing and an appropriate PPE. So, tick that.
Mike Lewis: I can give you examples of that in a large hospital setting. Also with the air clean systems, I was actually… I unfortunately couldn’t go and look up the value, because I had to go and see a patient, but I’m glad you reminded me it’s six air changes per hour. But in fact some of the ones I was looking at earlier today will do 20 air changes per hour, which is even better than your 15. And I think with that type of volume air clean, that’s the what we can say to people, “Look, we’re doing this. It’s safe to come into this environment.” I can’t agree with you more.
Nairn Wilson: How do we get out of this? Become part of the agenda and to get our message across. And disappointing if our CDOs are not part of the core team, or they’re saying these things and they’re not being listened to. I’m sure people have said these things to our chief dental officers and so on. And I feel sorry for them if they’re not being listened to, or I feel…
Nairn Wilson: Goodness what goes on? You have a chief dental officer, you ought to listen to them, yeah? If they’re not being listened to, that’s a real problem. I think one of the things that has to come out of this at the end of the day, other than getting dentistry up and running, and go back and say, “I think a great way to get it will be to be testing centres and get recognised through that.”
Nairn Wilson: We must address this once and for all, and be part of the healthcare agenda in this country and indeed internationally. As and when the next crisis, whatever it is and what shape it takes, whether it’s AIDS, respiratory, something else, we’re not the forgotten tribe of well-trained healthcare professionals who comply, who are good at this stuff, and can really make a difference and make a major contribution.
Nairn Wilson: We’re currently just forgotten, or we’re not on somebody’s radar screen. And that’s really, really sad. And one of the things I would like to do again with my new college is that very much a part of the agenda. Dentistry has never had its own independent college, let alone our own college. Maybe we’re not being heard because maybe the secretary of state says, “Get all the presidents of all colleges in here.”
Nairn Wilson: We’re not there, because we don’t have a college, let alone our own college. So, we’ve got to take all action we can to be at the right place and be at these high level meetings. So, the voice can say, “Hey, dentistry could really help here. We can do something.” And you could keep these dentists and their dental teams employed in the process, not run the risk of them all disappearing and going bust. And no dental service as and when we do get back to business. It’s sounds a no brainer to me.
Mike Lewis: That very point. When I was Dean of the Dental Faculty at the Royal College of Physicians and Surgeons in Glasgow, when I was chair of joint faculty meetings, I tried to get representation for dentistry from one of us from the four colleges onto the academy and medical and they said no. And what happened was one of the medical presidents or surgical presidents represented us, but I thought dentistry should have… And I fought and I did the battle for a year and I gave up.
Anthony Kilcoyn…: I think both guys have made great points. We need to raise dentistry’s profile. I suppose if there is a silver lining to this cloud, what I have noticed is a quite positive side effect is that it’s unified dentists and dentistry with a common sense of purpose. We’re all struggling in different ways. We’re all quite keen to get back to help patients.
Anthony Kilcoyn…: We’re all thinking in the same direction and we’re all feeling a little bit under utilised and unappreciated at the moment. There’s examples of colleagues now setting up urgent dental care centres. They’re buying their own PPE, they’re bringing in all these extra risk reduction things. There’s almost zero support coming in from the system and they’re the only ones who are trying to look after this tsunami of acute need patients at the moment. And it’s just totally inadequate.
Anthony Kilcoyn…: So, in a way by allowing a phase one in a bit perhaps earlier than they might have been thinking about, it would actually be a dual benefit. It would take some pressure out of the central system. Let’s be honest, by the time they get around to planning something that actually works, most practises could be looking after at least that level of acute care themselves, be doing it safely and well, following certain protocols, and doing risk reduction assessments.
Anthony Kilcoyn…: And, yeah, we can’t see 40 patients a day like that. We’re going to have to slow it down and have no more than one person in the waiting room and family members can sit in the car, or however we manage that. There’ll be ways of doing it. They’re going to be some people we’re still going to have to do an AGP on now. Now it might be we’re allowed to do one of those a day and they’re the last patient of the day. Whatever. There are ways to risk reduce, to risk mitigate, and to do it effectively and safely.
Anthony Kilcoyn…: And there’s certainly a big desire now in our profession to just… We’re doers, aren’t we? We want to crack on and get this solved. We don’t want bureaucratic barriers stopping us from providing the care we know we can do safely.
Prav: Tony, you mentioned about cracking on and doing and all the rest of it, and funnily enough I got off the phone with a colleague of mine who’s a dentist in Sweden this morning. And he’s a personal friend as well and I just said, “Listen, mate, what’s going on out there? How has dentistry changed?” And he said, “We’re operating at approximately 30% to 40% of our previous rate.”
Anthony Kilcoyn…: Yeah.
Prav: “We’re being sensible. We’re wearing visors. We didn’t wear visors before. There’s gaps between patients. We’re doing AGP and I am looking after my existing patients. I’m not taking on new business. I’m not advertising. I’m not doing any of that, but we are just being sensible about it.” Same story in Germany, same story in Finland I hear.
Prav: Do you think we should have taken that approach, or do you think the approach of completely closing down in line with letting the peak come and go and isolate was the right thing to do, or should have we been following our colleagues in Europe?
Anthony Kilcoyn…: Sure. I would just say one word of caution.
Anthony Kilcoyn…: If I look at it, I’m sure like my fellow two colleagues, we have lots of friends and connections.
Anthony Kilcoyn…: And academic…
Anthony Kilcoyn…: We have lots of friends and connections, academic as well as frontline level dentistry, and in the medical and especially virology, immunological… So it’s really interesting, isn’t it, just to compare-
Prav: Of course it is.
Anthony Kilcoyn…: … what a country’s done, different systems, how they’ve approached it. Do you know what? They’ve nearly all done it differently. They’ve been at different phases, with different problems at different times. We can pluck out the dental bits but we do have to be careful to see how has Sweden done that in the context of how they manage the general population, and that’s why it is a bit different.
Anthony Kilcoyn…: So I’ll give you one example of mine: Thailand. So I was there in January, speaking at a massive dental conference. It was like a joint conference between Thailand and Germany. It was just packed. Thousands of people, over a week. Of course, I’m arriving at the airport thinking, “Oh, why are they doing the thermal checks on the temperature as people arrive?” It is that part of the world where about 20% of the people walk around wearing masks anyway.
Anthony Kilcoyn…: It’s really interesting how they behave and interact. Very polite, lovely people. They always find it a bit strange when I put my hand out to handshake because it’s a nice, respectful bow, at a respectable distance. So they kind of respect personal space. There’s none of this hugging or French kissing on both cheeks, or whatever. Suddenly, as a lookback exercise now, I’m thinking, “Wow. They were already intrinsically safe in many ways that they behaved.”
Anthony Kilcoyn…: They’re not more high tech than us, although it has advanced a lot as a country, but I would say, probably because they’ve had experience of bird flus and swine flus and they’re in that Asian region where there’ve been many epidemics and pandemics before, they were far more prepared. They’re a far more compliant general population. Again, like us, they adhere to cross-infection control as dentists very well. But the first thing they did was, they had the sterilisation arches. So whenever you went to a shopping mall or anything like that, you had to walk through an arch and it would just spray a mist on you, which was antiviral or whatever. But everyone just cooperated with that. They’ve had a lockdown of sorts but it’s been a mild one, but what they haven’t done is the widespread testing in the population and so on. I think probably just because of costs and so on. But they took early preventive measures.
Anthony Kilcoyn…: Now, their dentists, they’ve stopped for a while and they’re starting again. They stopped for a while and they’re starting again. But do you know what the total number of deaths was? And I’m about a week and a half out. The total number of deaths from coronavirus in Thailand: 41.
Anthony Kilcoyn…: We were getting more an hour last week, of deaths.
Mike Lewis: Also, in South Korea, I was in South Korea a couple of years ago, and South Korea, I think their death toll is less than 40.
Anthony Kilcoyn…: Yeah. It’s incredible, isn’t it?
Mike Lewis: It’s similar behaviour.
Anthony Kilcoyn…: So the bigger picture is important. We pluck out the dental picture, which is actually very encouraging because, as you know, there’s been studies in Wuhan. They’ve even looked at the dentists who worked all the way through there and whilst there’s some casualties, it’s no worse than the general population. So it’s more likely that it happened out of dentistry than within.
Anthony Kilcoyn…: So there’s some hope that what we do is intrinsically protective but, again, I think we have these physiological barriers to overcome here, both for our own worry and our team’s concern, as well as the public. So I think it will be a turn the taps on, dip your toe in the waters, get a little confidence with that and you move forward from there.
Narin Wilson: Yeah. Our position in the U.K. is that we’re not integrated into general healthcare. Part of the issues in Thailand and Germany and Sweden, all these countries that we’ve mentioned, and many other countries around the world, dentistry is much greatly… much more value put on it and it is seen as an integral part of the healthcare system, and these people are very much part of it, not as an add-on as we often feel in this country.
Narin Wilson: One of the things I felt I failed to do in my career is to do this, to achieve it, and there’s all sorts of examples, issues about general anaesthesia and this and other, and various things. You go to government briefings and stuff and they produce stuff and you had to stand up and say, “When you talk about medicine, do you include dentistry or not?” Isn’t that sad, that we had to ask, “Does this apply to dentistry too?” Of course it ought to be because we’re meaning it to involve nurses, pharmacists, this, that and the other, but we weren’t sure whether it meant dentistry as well.
Narin Wilson: I think one of the things we must learn from this and take forward is we’ve got to address this, and we’ve got to put that one to bed and catch up with the rest of the world, that do value good oral healthcare and dentistry and appreciate it more than it has done so in this country.
Narin Wilson: But coming back, I very much hope that a way can be found to get us moving again. I totally agree with Tony. It’s a bit like the tsunami that cancer care and hip surgeons are going to have once they get started again. We’ve got the same problem. I agree entirely with it, and the sooner we get started and we can find a way to get in and use our expertise and our resources. It’s a wonderful geographic distribution of well-trained healthcare professionals, and here we are sitting frustrated.
Payman: What about going forward, the psychological part of it that we’re talking about? Firstly, for dentists and teams, will they feel confident going back, as far as safety? And then, secondly, patients. Even when, let’s say, the regulators or whatever decide that we can open, what can we do to encourage patients to come in? To the approach of, in the media, is it right to talk about aerosols in the media or isn’t it? This influence that you’re talking about, Prof. Wilson, do we get influence by politics or do we get that influence by media, or is it a combination? What are your thoughts on the psychological side?
Narin Wilson: I think you’ve got to fire on all fronts: media, politicians, et cetera, and do it in a meaningful way, not get angry and aggressive because that never helps. Gently reminding people, “Hey, we’re here. We can really help. We can do things,” et cetera. It won’t be the regulator. It’s impressing departments of health, Public Health England, NHS England, the Chief Medical Officer and the Chief Dental Officer to think afresh and to stand back and say we must embrace this, all aspects of dentistry. Not just the NHS, the whole of dentistry, including private dentists as well. If you said to a private dentist, “Will you help? You can make a difference,”… of course a bit of funding to cover costs, et cetera… I bet you they’d all say, “Of course I’ll do it.”
Payman: Yeah, of course they will.
Narin Wilson: We’re a very professional group of people. As Tony said, just give us a chance. If we’re given the chance, I think we’ll get the route in to getting back, and getting back and established. I think a lot of the psychology, if we embraced by the system and they talked to us in the way that they talk about nursing and pharmacy and so on, then I think that would have a great transformation in the public perception of dentists as well. If we were seen to be part of the family, I think that would make our lives a lot easier. I think part of it is that we’ve, historically, not been included. I think getting around that psychological stuff, if we were integrated and we were talked about as if we were part of the healthcare family, I think a lot of these issues would disappear or be a hell of a lot easier to deal with than they are as at present.
Prav: I know we’re running short on time and something that’s very high on the agenda that I mentioned earlier on is what is this new SOPO protocol going to look like when we come back to dentistry. Let’s say when we come back to AGP dentistry, for example. I think if anyone can answer this question you guys can, having the research background that you have.
Prav: The key things that have been brought up in conversation after conversation is PPE and the level of it. Obviously, high volume aspiration. Fogging. Hyperchlorus in the lines. Clean air technology. And then another hood of suction that sits above the patient that sucks some air out. So it’s almost like some practises are going like absolutely ninja on this, right? I’m looking at this and thinking, “How is this sustainable?” And if
Anthony Kilcoyn…: It sounds like we’re going on stage of Britain’s Got Talent and the fog clears and the dentist appears in full PPE from head to toe with the patient in the chair!
Prav: Absolutely. And gives
Anthony Kilcoyn…: Look. I’m on many forums and still Zoom, and meet with many dentists up and down the country. Because there isn’t this guidance that’s clear for all of us, we’re all making up our own and chucking it into the pot, and it’s just chaos, and that’s worrying.
Anthony Kilcoyn…: Cut a long story short because I realise we’re running out of time. The best one I’ve seen so far, and I hope Mike Lewis agrees with me, is the Welsh SOP. They released it only just a week ago, so it’s one of the most modern ones as well. I would still pick faults at it and adjust things in it but if you’re going to score something nine out of 10, it would be that. So I think that’s a good basis for the other CDOs to look at that and adapt it, and then just modernise it again in another week or so because it will be two weeks out of date by then.
Anthony Kilcoyn…: We’ve got through April. We’ve got through the peak risk to the general NHS system. I’m kind of half pleased we’re not hearing much about Nightingale and the ExCel Centre because it’s not getting used. Apparently the Birmingham one’s totally unused. So we’ve now got excess capacity with the ventilators and the ICUs and so on.
Anthony Kilcoyn…: So the general burden on the NHS, yeah, it’s still big, we still need to applaud them every Thursday night at eight o’clock, but it’s not what it was and now, this is 1st of May, I think we can start looking forward instead of backwards and start planning it. But you’re right, we need something to say, “Look, this is the start. Use this as an example.” But it’s a continual process. We’ll all have to adapt it in risk assessing our own environments.
Prav: Tony, are you a practise owner?
Anthony Kilcoyn…: Yes.
Prav: So what would your SOP be going back, and obviously I don’t
Anthony Kilcoyn…: Well, I can tell you mine.
Anthony Kilcoyn…: We’ll be here all day. So I’ve already been
Payman: I’m sure you wrote an article 10 years ago about this.
Anthony Kilcoyn…: Yeah, I did. I wrote an article 10 years ago almost predicting this, I would be wiping door handles down and so on. So those are our protocols. I’m hardly going to have to do… I will have to do some things but I’m not going to have to change much. I think there’ll be a lot more prescreening before people come down, and so on. Mine is a private practise. So I have more time per patient and I don’t have 10, 15 people sat in the waiting room all the time. So actually it lends itself to this.
Anthony Kilcoyn…: So I think NHS systems are going to have to change and start looking at units of dental time and making it practical and work, and that’s a subject for a whole other seminar I’m afraid. The private practise will have to adapt but it isn’t going to have to adapt that much. It isn’t going to have to adapt that much because it’s already kind of units of dental time focused. Dentistry is very good at finding solutions to problems. That’s what we do, that’s our day job. So someone needs to just bring this together and give us the starting point. Let us go, and we’ll evolve quite quickly.
Prav: Am I right in assuming that NHS and private dentistry will be measured by the same yardstick, so the same standards will apply? Because, from my understanding, I might be incorrect here, the CDO is the voice for NHS dentistry. It that right?
Narin Wilson: No.
Prav: Oh, is that not right?
Narin Wilson: The role of the all the CDOs is very careful, it’s overall responsibility for the oral healthcare of the nation. They have a focus on NHS understandably, because that’s the government funded side of it, but the role is to advise ministers and so on on the oral healthcare of the nation. Yeah?
Narin Wilson: We, as a profession, should work… and I keep thinking it’s so unfortunate that we have this division because most practises are mixed economy anyway, and that’s another thing I would like to see getting rid of. This is the nature of the beast. Very few people can survive on NHS only. Hardly the entity of an NHS practise because most practise has got an element of private, they’re all mixed economy, and there’s relatively few absolutely purely private that don’t do anything in the NHS. So we should, again, try and get away from this. We’re dentistry and we’re dental practises, and of course we’re there to serve patients first and foremost. We do it in subtly different ways.
Narin Wilson: If I come back on the guidance, it will never be specific for everybody because all the practise and configurations and the nature of them, the age of the building, quality of the ventilation, all the rest of it, as with anything, the guidance will be a bit generic and it requires our professionalism again to apply the rules and make them work in all of these different environments, that you feel safe, your staff and your dental team feel safe, and your patients are going to feel safe about coming into it.
Payman: When we talk about going back to normal, one thing I wouldn’t want to go back to normal is the volumes of patients the NHS dentists are seeing because if you look at… they’re seeing 30 to 40 patients a day. If you look at a five minute clean up in between those, it’s impossible to see 30 or 40 patients a day. So the clean up must be one minute, and one minute’s not enough to clean the surgery pre-COVID.
Payman: So if something can come out of all of this, perhaps it’s that the NHS has to change, and maybe that means people have to start saving for their dentistry, which hasn’t been in the culture here as it has been in lots of other countries. But we do need to pull out some silver linings from this cloud, and I think that will be one of them, that the NHS finally changes and either becomes a core service or more money goes into it, God forbid! But somehow I don’t think that’s going to happen. But who’s going to pay for it?
Anthony Kilcoyn…: I would just say, that’s been an ongoing issue since UDAs came in in 2006. Target-based healthcare-
Narin Wilson: Even before then though.
Anthony Kilcoyn…: … has been recognised as not good anyway. So maybe this will be the catalyst that finally drives some change. Instead of having pilot after pilot after pilot and kicking the can down the road, maybe finally someone will go, “You know what? Let’s grasp this nettle. Let’s make something fit for purpose.”
Narin Wilson: I couldn’t agree more, Tony. No disrespect, something like the Jimmy Steele report, lots of great stuff in it, still relevant, but that’s now… how old is that? 12, 13, 14 years, and the world has changed in that time, let alone through this episode, and we can’t be building a system on a report that’s that old, and through this.
Narin Wilson: I couldn’t agree more that, again, a fresh approach, a fresh look at this, the feasibility of quick turnaround, high volume patients, et cetera, it’s not going to work. In a new world and the new norm, there is a need, and a realisation that… and your pragmatism about what money can be afforded for oral healthcare and how do we spend that best. If, in the grand scale of things, as is common in most countries, total spend on health, that you can afford 2%, 3%, or something, of the total spend relative to cancer and all the other things you do, and that’s about what the level is, what can we do with that money and use it to best possible advantage to achieve something that we can all be proud about, and we can all sign up to and move on.
Narin Wilson: Yes, I think if there’s a silver lining, it should precipitate a fresh look and a fresh consideration of we need oral healthcare, it’s important to general health, let’s do it in a way that can be a good use of money and can be most effective, and we can all feel very proud about it and get on with it.
Mike Lewis: Just have to say I absolutely, totally agree. Gentleman, I am going to have to go in five minutes because I’ve got a patient to see in the emergency clinic. I’ve found this last hour fantastic. It’s a great opportunity to have discussed this problem from the various angles that we’re coming from. I thoroughly enjoyed it, and I hope that anyone that watches this comes out with… gets the impression that we are all trying to work to the common good to get our profession back on the road and in the best possible shape.
Anthony Kilcoyn…: I agree.
Prav: Thank you so much.
Mike Lewis: Thank you.
Payman: Thank you. Maybe we’ll reconvene in a month and see where we are.
Mike Lewis: Indeed, indeed. On PPE.
Payman: Thanks a lot, guys. Thank you so much for taking the time. I know you’re all busy.
Anthony Kilcoyn…: Thank you.
Mike Lewis: Thank you very much. See you, guys.
Mike Lewis: Bye, everybody.
Anthony Kilcoyn…: Cheers.
Outro Voice: This is Dental Leaders, the podcast where you get to go one-on-one with emerging leaders in dentistry. Your hosts, Payman Langroudi and Prav Solanki.