Faced with a lack of clear advice, guidance and representation, dentists have taken the unprecedented step of forming a new association.
The British Association of Private Dentistry (BAPD) started out as an online grassroots movement in response to the COVID-19 crisis and quickly gained a huge following.
In the first of our topical buletin shows, Prav and Pay are joined by BAPD co-founders Jason Smithson and Bertie Napier, alongside implant dentist Dominic O’Hooley, who co-authored a report on AGPs and infection.
They talk about the science of transmission, the need for better industry representation and much more.
“One of the things I’ll be looking for is a GDC that’s by dentists for dentists. So that wet-finger dentists are integral and central to the regulatory process for dentists in the U.K. And I’ll leave it at that.” – Dominic O’Hooley
Watch the video of the interview here:
00.38 – Welcome to our guests
02.38 – Aerosols and viral transmission
10.02 – Precautions and public perception
21.02 – Airborne threat
27.04 – Dentists and infection rates
32.43 – The pathway back to work
37.59 – Private dentistry and representation
54.25 – Silver linings
1.00.41 – Back to work
Connect with Prav and Payman:
Payman: When will we not, when should we do?
Bertie: June, definitely, that’s me, yeah.
Jason Smithson: It’s because the cogs are very big and turn very slowly. That’s the problem.
Prav: Are you saying 1st of June as well, Jason?
Jason Smithson: Is 1st of June a Monday? If it were a Sunday, I would say no, I haven’t got a calendar at hand.
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: As we enter week seven of the lockdown, many of us are looking at the virus, and we passed the peak in, at least, in metropolitan areas. I know there’s other parts of the country where they’re just going into that. But at the same time, we’re looking at the unlock. There’s patients with untold misery out there and there’s practises who are sitting on their hands. We’ve got dental professionals who can’t treat those patients while they clog up the one-on-one system and A&E. And so, we thought it would make sense to try and unlock this, and we’ve got three guests from the British Association of Private Dentistry which has recently been formed. So let’s welcome the guests. We’ve got Dominic O’hooley on the scientific community who’s done outstanding work looking at all the latest research.
Payman: And guys, before I go any further, I just want to thank the three of you and I know there’s a bigger team behind you guys for all the work you’re doing for the profession. Someone needs to stand up, step up, while we’ve got such a vacuum of advice coming from the top. We’ve got Jason Smithson who kind of started the BAPD with a few others with Zacky and with Neil and the others and has done stunning work on the political side and I think you guys are coming out with a bunch of recommendations for back to practise guidelines. And we’ve got Bertie Napier, who’s on the comm side and on the bunch of other sides of the BAPD, former president of the BACD as well. Lovely to have you all. So let’s start with Dom. Dom, where are we as far as you can see, we’ve got this aerosol issue which you put out your document on. Do you want to summarise what that document said and your thoughts going forward on what dentists should be doing next?
Dominic O’Hoole…: Happy to do that. Really just a little disclaimer to begin with, I’m just a dentist. Because I’m just a dentist, I’m able to look at all the research very carefully and one of my little things is that I am quite geeky with regards to that. So I have spent a lot of time collating and curating that research data together. And it’s provided me with the opportunity to formulate an opinion on this. And it’s not 100% clear, but we’re getting clearer that the two primary methods of transmission of the SARS-COV-2 virus are via droplet spread and something called ballistic droplet events. And the second one is by a surface spread through things called fomites.
Dominic O’Hoole…: And the issue with what we call dental aerosol generating procedures is a bit of a misnomer. And what we seem to be seeing with the literature now is that there is a consensus developing, the aerosol spread of SARS-COV-2 is not regarded as the primary vector of infection. And so, therefore we have to be very careful if we’re looking at a science based approach to going back to practise, that we don’t run down roads that are not going to lead us to a very effective way back. And we end up perhaps purchasing very expensive pieces of kit, that actually don’t provide us with any risk mitigation for our patients whatsoever and don’t provide our staff with any safety benefits either. So that’s really where I am at the moment with that.
Payman: Okay. Jason, you want to jump in?
Jason Smithson: And well I can just really only agree with Dominic and I think our main concern as a profession, certainly one of mine, is if we’re going to go back to restricted procedures, so we’re going to go back to aerosol producing or non-aerosol producing procedures without really any science base. And we have the other concern, if we go back to only completing non-aerosol producing procedures, what happens, as we discussed yesterday, what happens if the patient coughs? Which is as Dominic will probably confirm is a ballistic droplet event that non-aerosol producing procedures suddenly becomes potentially quite dangerous. Yeah, so that’s where we are.
Payman: Okay. So what I’m hearing you say is you don’t see a good margin of difference between a non-aerosol producing procedure and an aerosol producing procedure?
Jason Smithson: I don’t see any difference at all, but I think the first… I should really preface that by saying I think we should go back safely. So I think there are certain things we should be looking at and we’re currently, in the British Association of Private Dentistry, working on some forms of guidelines for that literally right now. But one of the things I strongly believe is that there doesn’t really seem to be much difference in risk between aerosol producing and non-aerosol producing, even though we’re going down that route quite seriously. So, that’s where we are with that. Dom, do you want to chip in on that? Because I think that will be valuable.
Dominic O’Hoole…: I’m just going to briefly chip in to just say that every time we… As I said in my paper, every time we breathe, we create a respiratory secretion aerosol. And so, there’s a bit of a false differential between aerosol generating procedures in dentistry and just being alive. And so, we’ve got to be very careful that we’re aware of the fact that when we use our humpies or our cavitron or the pieces of equipment in the dental surgery, they create clean wall on aerosols and these things are usually, it’s either clean sterilised water, or it’s an antimicrobial that’s used in those. And it’s only when it actually impacts into the oral commissure that you actually get what we call a mixed aerosol.
Dominic O’Hoole…: And there is real positive studies with regard to mixed dental aerosols. But what I would say is, I think Jason’s very correct in saying that I think it’s very wrong of us to have a red flag for dental aerosol generating procedures on one side and non-aerosol generating procedures on the other. I think what we’ve got to do is we’ve got to look at a risk mitigation approach to get back into practise with safety for our patients and staff at the heart of that. But at the same time keeping our eyes on the evidence all the time and not going down an emotive route. So anyway, that’s my kind of point where regards to that.
Jason Smithson: I would kind of add to that in a practical terms, what is the real difference in doing, for example, an extraction on a perhaps an older person with chest issues who may be coughing throughout the procedure in comparison, which is considered a non-aerosol generating procedure, in comparison to putting a rubber dam on and doing a small cavity or perhaps even a root canal access on a fit, healthy patient who is not coughing. And that would be considered to be an aerosol generating procedure. In my opinion as a dentist, I think my risk would be higher in the first approach rather than the second. And yet the guidelines are for us to do non-aerosol generating procedures.
Bertie: I think I’d like to support what Jason and what Dom are saying. And I think the first thing that resonated with me immediately with some of Dom’s work was, there’s a difference between an aerosol generating procedure or aerosol and droplets spread. These are two completely different things. And I think what’s tending to happen is this has all been lumped into one thing. And this is where the confusion is coming in for so many people. And we’ve also got to look at the history of dentistry as well. We’ve been faced with other epidemics in the past. We’ve had the SARS thing, I think it was 2003, we’ve had MERS previously and none of these things have we ever had where dental practise or the practise of dentistry has resulted in a massive or what we call a Super-spreader event.
Bertie: If we’ve read Dominic’s document, it’s got a very clear explanation of a Super-spreader event. And dentistry has never been that. So for people to come out and say that these aerosol generating procedures are, so, I think I’m going to use the words that have been used, dangerous without having any scientific backing to make that statement is a bit questionable.
Prav: I’ve got a question for you guys. Well, how do you think all of this media attention is going to impact the public perception of the safety of dentistry or how safe it is to walk into the practise? And I’ll just add to that, that I’ve seen and I think to share the video with you guys this morning, people have started to advertise their practises as the safest place to come in: “Look at the precautions we’re taking. Look at this air purification. Look at this space suit that I’m wearing.” And to me, that feels like you’re saying to the patient, “The dentist is an unsafe place to go, unless we’re kitted up like this.” My fear is that is we’re putting the news out there in the public that it’s an unsafe place to go.
Bertie: Which is a big problem. That is a big problem. I was on the phone with my son just a few minutes ago and these are his words exactly, “Come on dad, when you walk into a dental surgery, you probably know that it’s the cleanest place you’ve been in that day. If you’ve been in the supermarket, the tube, the train, on a bus, in a taxi, when you walk into the dentist surgery, that is probably the cleanest place you’ve been in that day.” And that says it.
Jason Smithson: I actually went on Friday evening out to get fish and chips for my kids, because they going crazy, they wanted take away food. And obviously, fish and chip shops have a health and safety regulations and actually CQC as well, which is one of our regulators, and standing outside the fish and chip shop at a two metre distance from all the other clients, I didn’t notice any masks on the people serving the fish and chips, I didn’t notice any gloves, I didn’t notice any significant wipe down of surfaces between people even though they are handing over money and putting their hands on the counter. And the fish and chip shop is open, providing a nice service and great but a non-essential service. Meanwhile we have, in my area people with fat faces, people with tooth ache, people with broken teeth and we have a very strong longterm record, I think since HIV, I think it’s fair to say, we’ve had a very good, strong longterm record for cleanliness and sterility in our surgeries and yet we are closed and patients are walking around in agony. Now, is that correct?
Dominic O’Hoole…: Can I just jump in that Prav, just to go back to your point, I think there’s two issues. I think Jason has very neatly summarised that, and I think so as Bertie. But what I’d say is I think that we had a little bit of a vacuum of leadership at the beginning of this. So unlike Wales and Scotland for example, we didn’t get really leadership from the top. This kind of vacuum created a situation where there was a real hunger for information happening and it wasn’t coming through. And I think the public were aware of that. And I think the second thing that happened is that when the urgent dental care centres opened, I think there was a second level of misspeaking information coming from the top with regards to the number of these urgent dental care centres and how many of them were actually ready to see patients.
Dominic O’Hoole…: And I think this fed into the general media worry regarding PPE. And it didn’t do the dental profession any favours at that time. Because I think that it tied in quite closely with the very many media reports we were seeing of patients who were having to do their own treatments, take their own teeth out and things like that. So from a dental profession point of view, I think that there was an issue with regard to how our leadership showed leadership with regards to this pandemic. Now I think going to your second point, I think if you look at what you were mentioning about potentially practises or corporates using a safety differential to kind of give themselves a commercial advantage over the other corporates or perhaps or the dental practises, well for me, I’m going to be quite open about this, I think that’s an example of naked profiteering.
Dominic O’Hoole…: And if it’s not science-based, I’m concerned about it very much. What I would say is that it’s perfectly reasonable for people to perhaps purchase things such as air purifiers, if they feel that that’s going to give the right message to their staff and it’s going to say to the staff, “Look, we’re willing to spend and invest in this kit. We know it hasn’t got a lot of evidence behind it. We’re going to invest it because we want you to feel safe to come back to work.” And I think that’s an entirely honourable way to go forward. But I think where it’s very different is if they start using these potential own evidence-based, pieces of kit to create this kind of safety focus that is not really true. And I think that’s not really what we should be doing as a profession. I think if patients go to a specific practise because they’ve got an app purifier, then I think we failed as a profession being true and honest to our patients.
Payman: Look, certainly I don’t think from a marketing perspective it makes much sense anyway. I think it makes you feel unsafe when you talk about this. But Dom, from your experience, from your research that you’ve done, what would you say is safe as far as equipment, air purification, high-volume suction, masks, what would you say, if you ruled the world, what would you say is the standard that we should be following?
Dominic O’Hoole…: I think if I ruled the world, we’d be in even worse situation than we are now. Well to be serious, I think if we got back to the premise that dentists, as Jason, and Bertie as well is, dentists have got a long history of being the experts of universal precautions. We’re absolutely au fait doing cross infection control extremely well. And we’re taught about at undergraduate level, and is then instilled in us as dental professionals going forward. So from my point of view, we are in a great position to be able to provide a safe environment for our patients. And that to me provides me with this troubling thought that we’ve been closed down. And yet as Jason said, so many others seem to be open where there is not the same level of regulatory control and we’ve got patients walking around with severe tooth ache and potentially very serious morbidity happening.
Dominic O’Hoole…: So go into your specific points. I think that if we look at what we always did first, so I think that the use of surgical masks which prevents a lot of wearer associated infection to patients because it’s a preventative measure in that way. The full face shield which prevents what we’ve talked about, the droplet ballistic events contacting the moist areas of the face, so your eyes, your nose and your mouth. The use of very careful and meticulous clean down between patients that we’re well aware and we use regularly already. These are the sort of areas where I think that we’ve already got an existing safety function for our practises. We use antimicrobials in many cases within our dental waterlines. Originally this was to reduce or remove biofilm within the waterlines. However, it seems logical to me for those antimicrobials to be used for a secondary function, which is to potentially reduce the viral load within patient’s mouth as well.
Dominic O’Hoole…: I think it’s interesting to look for us, and we are looking at this at the moment, to be looking at preoperative mouth rinses, to think about another way of reducing that viral load within the mouth. And it’s a simple, safe and effective way to make a material difference to the risk to our patients in our practises. And I think that when you start looking at really, really less evidence-based things such as floor standing air purification systems, wall mounted ones, or the ceiling mounted ones, I think the real issue there is twofold.
Dominic O’Hoole…: I think one issue is that they are not evidence-based and they’re absolutely very, very poor and limited amount of evidence that’s available doesn’t support the use. And then secondly, that they’ve become an extremely commercially sensitive product that appears to be pushed to people who are in a position where they feel they want to get back to work. So there’s an almost a mass hysteria going on. “We’ve got to go back to work. We need to do this. We need to do that. We need to buy this.” And the problem with doing that is, that if it isn’t evidence-based, we’re actually spending money on things that are not going to make a material difference whatsoever to our patients.
Jason Smithson: Yeah. The other thing Dom is perhaps the rubber dam, which is the other big aspect. The use of rubber dam reduces obviously ballistic droplets if the patient were to cough whilst you’re working. So all of those things really, I think that Dom’s mentioned, barring the pretreatment mouth rinse, we’ve pretty much been doing anyway, we all been wearing a mask, most of us wear a visor, we all cleaned down between our patients and ideally, you should be using rubber dam. So it’s not like you’re going to have to rip your surgery apart and put big glass shields at the reception and put huge air purifiers everywhere, and this and the other. The fact is we’ve already been working to a very, very high standard as dentists anyway. And that’s actually interesting enough, that’s actually been reflected in the research shows that the transmission rates to dentists over the last two to three months have been very, very low. In fact, no difference from the general population.
Payman: Globally as well, that’s what-
Jason Smithson: Globally. Yeah.
Payman: What would you suggest regarding virus in the air, how long does it stay there? How much of it gets there? and high volume suction is used, what percentage of it is taken out?
Dominic O’Hoole…: This is very interesting. I think without going into too much detail, if we look at actually the virus measure in aerosol first. So if we’re looking at trying to measure SARS-COV-2, in aerosol, there is a recent study that came from two hospitals in Wuhan, which looked to collecting a proxy measure of the virus within, it ended up being two specific areas of the hospital. One was patient toilets, and the second area was areas where soiled PPA was removed or doffed. And what they did there, is they actually were able to measure viral RNA and they admitted in the paper there’s an issue with that.
Dominic O’Hoole…: The issue is that viral RNA doesn’t tell you if it’s effective virus or not. It just tells you that it’s either dead, demoted or potentially live virus there at some point. So the second issue that was there is that, one of the most heavily measured areas was the patient’s toilets, and it seems that something called faecal airialization which is where your toilet flush. I know this is a bit disgusting, but this is another way that we can actually obscure SARS-COV-2 enter aerosol is through toilet flushing.
Dominic O’Hoole…: So there’s a lot of problems with that paper and I don’t think that it provides really anything like weighty evidence to suggest a change in the consensus that we’re looking at primarily droplet and surface primary spread. So thinking about your point there Payman, regarding aspirators. I think what’s interesting there is that it’s very clear that high volume aspiration, just from a visual point of view, takes away the vast majority of the aerosol that’s generate as you do in your procedures.
Dominic O’Hoole…: If you tie that in with what Jason mentioned, that using rubber dam where possible, obviously you can’t do that if you’re doing-
Jason Smithson: Scaling.
Dominic O’Hoole…: … scaling and things like that. In a way you can use it. But at the same time if you use a really efficient, high volume aspiration and if you’re making ensure that your nurse is trained in forehand dentistry so that she can provide you with optimum aspiration, then it’s a very effective method of reducing the aerosol generated by your dental procedure. And you can see that on your face mask. Just a simple measure look at your face mask if it’s been done properly and it remains very clean. So with regard to formalise measuring of that, I don’t think there’s been any studies that have shown a percentage of their aerosol is taken away by high volume aspiration. But it seems to be a large, large majority of it.
Payman: Well I think that then works into the N95, the FFP2, FFP3 story. Once you layer the reduction that you get from rubber dam and high volume aspiration, layer on to that the small percentage difference between these masks, the differences we’re talking about between surgical masks and the top mask might be a 1% difference at the most. And you were making-
Jason Smithson: I can tell you exactly what it is in a moment.
Payman: Oh go ahead.
Jason Smithson: Give me a moment,
Payman: But Dom made a very excellent point when I spoke to him, that the FFP3 mask is an uncomfortable thing. We’ve been advised to wear it all day. And inevitably as dentists, we know inevitably you’re going to touch that thing, particularly when it’s uncomfortable. And so any marginal gain you would have got from that mask is immediately lost because you touch it so much. So the idea that keeping a mask on between two patients just seems ridiculous anyway to us because we’re so used to changing things. But what it says to me is possibly a surgical mask is safer than FFP3 mask because of these nuances.
Jason Smithson: The differences 0.4% before we go forward.
Dominic O’Hoole…: I think one of the issues is that when FFP3 masks were used in COVID wards with patients who’ve all got COVID-19, there was a recommendation made for various reasons that they shouldn’t be changing those FFP3 masks all the time, they should be wearing them. And part of that, possibly was due to a lack of PPE. But there was a very good reason for it as well insofar as you can’t really infect people who were already infected. But when you come to dentistry, the vast majority of our patients are actually noninfected. There will be a subset of patients who’ve got subclinical or asymptomatic infection, but most of them won’t. And that suggests that after every single patient we need to change the FFP3 mask. And that gives you an issue with regards to the actual practicality of that measure in the longer term.
Dominic O’Hoole…: The other thing with FFP3 masks particularly, is that the tight fitting nature of the mask means that… Studies have shown you actually tend to adjust the mask more often and bring… You actually put your hands onto the mask a lot and they’ve noticed areas of former generation around the handle of the mandible with these masks. And the other thing they’ve noticed for certain people, is that they actually end up with a form of bad sores on the face from wearing these masks. They get surgical sores around where the mask fits. So for various reasons, I think that if you can actually avoid moving down this route towards this really, really uncomfortable type of mask, then we should do so if all possible.
Prav: Just a question that’s not COVID related but related to dentists working in close proximity of the mouth, precovid, influenza, is there any evidence to suggest that the infection rate to dentists without wearing a shield and cracking on is normal and the rate of infection with influenza is actually higher amongst dentists because you’re in and out of people’s mouth all day, every day, some of them are probably coughing, You’ve got these ballistic events, you do an AGP all day long, surely the infection rate amongst dentists with influenza, you’d expect it to be a lot higher, right?
Jason Smithson: Well Andre Haigh actually did the research on COVID with the same model so it’s probably more useful. I think Dom can probably fill you in on that because he has a co-author.
Dominic O’Hoole…: Well I can. With regards to COVID, it’s clear there isn’t an increased infection rate if you use the proxy outcome of a self-diagnosed infection because what we weren’t able to do, was actually use formalised testing. But if we go back to your point Prav, with regard to influenza, there are no studies that suggest an increased infection rate in dentists worldwide for influenza and that can be for many reasons. I think one of them is that our existing crossing function control measures are adequate. For a well recognised respiratory pathogen, they work well. I think the second reason is that there is some argument that we are quite a essentially healthy population base and that we may due to micro exposures to all these different pathogens every hour of our working lives.
Dominic O’Hoole…: We might have actually primed our innate immunity in some way to be actually almost like we’ve got super human… not super human immunity, but we’ve got really well functioning immunity. That in another way, what we do for a living is actually possibly protected us slightly. When you look at studies of dentists, they seem to be healthy individuals who unfortunately we find that they’ve got a lot of orthopaedic problems from being bent over patients looking like prawns. I think there’s something about slight increase in kidney disorders. And there’s also unfortunately very, very sadly, there’s a high rate of suicide in dentist, but there’s absolutely no evidence whatsoever of an increased risk of infective disease, of any type in dentists.
Payman: What do you attribute the fact that… I’m not sure you know better than me, but the fact that ENT surgeons do seem to catch coronavirus now?
Dominic O’Hoole…: I think that’s very interesting and it’s a really important point. I think the first thing to say is that these were very early in the coronavirus pandemic, that there were reports of excess infectivity among ENT surgeons and ophthalmologists as well actually, and these were what we’d call anecdotal reports at that time. So there was no very, very detailed specific study that was double blind and randomised that showed that there was an actually increased risk in those surgical subgroups. Because people have tended to adopt different precautions since that, we don’t really have any further evidence since those early reports. I think the second thing to be aware of, and this is, again, entirely anecdotal, is that we’ve got to ask ourselves, are they always using there PPEs effectively as dentists are? And were they doing that before this crisis? And I wouldn’t like to allude negatively in any way, but I would say that there are some anecdotal reports that they use of masks and eye protection among those groups for routine procedures, where as not as widespread as it is in dentistry.
Payman: I think you’re right. I mean after I spoke to you on this subject, I spoke to an ophthalmologist about it and he said, “Look, we only have two states, totally a septic or dirty and there isn’t a one in between.” And what he said to me was in the consultations and he said it for EMT as well, outside of operations, they never wear a mask. So they’re doing a consult, they’re right close up. He mentioned something about tidal breathing. You were saying as well that the volume you speak at all of these stuff actually affects the amount of virus coming out of you. But it’s a very interesting point because, yeah, we seem to, Because of our history, we have a mask on at all times and in hospitals, Dominic O’Hooley was making a point. If you visit the hospital, you can see this cross infection breaches happening just at every point. It’s very interesting. So now going forward, with all of this evidence you guys are producing this document what else would the document comprise of? Are you looking at other countries? Are you looking at other professions?
Jason Smithson: We’ve looked at other countries fairly comprehensively, but we’ve written a report, which, well, we’re just editing it right now, aren’t we Bertie?
Jason Smithson: it’s very close actually. Should I say it will be out tomorrow? Is that too much? Maybe Thursday.
Bertie: Thursday for sure.
Jason Smithson: Yeah, we’ll see. But it compares and contrasts what’s going on in other countries with what’s going on in the UK. I’ve just read it this morning for the third time. And what strikes me is the countries that have done well and are currently getting back to work. A good example would be Australia. You would see a very, very coordinated approach and a very organised approach to managing the disease. For example, in Australia the government was advised very strongly by the ADA, the Australian Dental Association, and all of the correct evidence and the pathways back to work, the various levels of getting back to work were all displayed on the ADA website. So that means that the dentists in Australia had the ability to get the correct information from one site rather than running around like headless chickens looking at things on Facebook, which is perhaps not the best way to do things.
Jason Smithson: And that’s very similar in New Zealand. Canada is slightly different, they went state by state, but they also had very coordinated ability through their state websites or through their province websites. And I think I’m correct in saying Denmark was pretty much the same. Is that right Bertie?
Jason Smithson: Yeah. So yeah, the paper will be out quite soon but it’s quite interesting.
Prav: Just in terms of going back to dentistry based on what you guys have said today, we should be going back when we go back I’ll be able to do AGP from day one. Am I hearing that correctly with the right precautions?
Dominic O’Hoole…: You are from my point of view.
Jason Smithson: Yeah. There are some small differences we’ll have to make, but I’m not seeing a vast difference in dental practise. Maybe for some people, but not a vast difference in past good practise. Let’s say that.
Dominic O’Hoole…: The other thing to say there I think is really important is that the absolute key to this is very effective patient pre-screening. And I think that’s going to tie in with an enhanced and improved testing policy UK-wide. I think understanding the parameters of what level of asymptomatic people we’ve got in the population and what level of people have the infection and what their immunity is. And whether we go forward with formalised immunity, passports and that kind of thing. I think it’s dependent on further scientific knowledge on the levels and the efficacy of immunity anyway. And also there’s some other aspects with regard to personal freedoms and things like that. But for me, I think patient pre-screening is an absolute key. And then looking at patient throughput into and out of the practise.
Dominic O’Hoole…: And I think we can make subtle modifications to that to avoid our waiting rooms being full of patients sitting two foot away from each other, chatting into each other’s faces and potentially things such as perhaps putting screens, partial screens between reception and other areas, and looking at trying to avoid contact transactions. So therefore, using money free and contactless payments as much as possible to try and limit the amount of surface contact that we’re having with things such as cash machines and card readers, and pens and things like that. So there’s a lot of things we can do to adopt that best practise. Well, the bottom line from my point of view, and this is my opinion, is that there is nothing where we can not think about, as a profession, that should stop us going back to a full range of dental procedures when we go back.
Prav: Who decides how we go back in what capacity when we can and can’t do AGP? Is that down to the CDO? Is that down to dentists and individual practitioners discretion? Have you guys got the answers to that or do we just simply don’t know?
Jason Smithson: I think Bertie can answer that, I think.
Bertie: Look, we’ve been told by the CDO that she doesn’t speak for private dentistry. The reality is that whatever she says, we are expected to comply with because if you listen to our defence organisations, they’ve made it pretty clear that if we don’t follow CDO guidelines, we need to have a very good reason as to why we haven’t done that. And I think the danger is, this is the only danger, and it’s not to do with dentistry being dangerous, the danger is that if somebody contracts COVID-19 somewhere else, and they’ve been to the dentist, this is what the defence organisations are pointing at and saying, “Oh, it’ll be difficult to defend or it’s going to create a case that wasn’t even there.” Yeah. We know the cases, the cases are not good, but just going back to who’s making the decisions in the end.
Bertie: What this whole thing has highlighted for us is there’s a massive void in representation of all of dentistry at the highest level. So we’ve got a big representation for NHS dentistry which is the CDO. We’ve got the BDA doing its best to represent dentists, but when it comes to the whole profession being represented, especially a strong voice for private dentistry, which has got a massive contribution to primary dental care, we simply don’t have a voice. So the decision is going to be made by others on our behalf, but we are doing our level best to change that. And that’s part of what the BAPD is about. Is to make sure that that change actually happens.
Bertie: I don’t believe that we would be in the situation we’re in now if there was a stronger representation for private dentistry in the first instance. I do think things have gone wrong. It’s not about pointing fingers, but we cannot let this carry on. So we are doing our best to try and have input at the highest levels possible. I think you’ve heard from Dom’s contribution to this conversation today, that there are people out there who are doing well, who are wet finger dentists who are really, really good at looking at the research and applying these things. Yeah. The decision. Yup. Somebody else is probably going to make the decision, but we’re doing our best to influence that decision now.
Payman: It’s high time, we had a BAPD even without coronavirus. But it’s accelerated it now. And that’s a good thing in a way for private dentistry. But how did you guys achieve so quickly? With regards to parliament, all those MPS signing the letters? What did you do differently?
Jason Smithson: I think it was way to numbers. I think everybody in the group, and by the group, I don’t mean the committee, I mean the whole group, the whole 8,000 members, PUT their shoulder to the wheel, they signed all the petitions. We released, I don’t know how many petitions, perhaps six. They all signed those. They, hopefully all wrote to their MPS. I can’t remember how many DMs I used to get up to in the morning saying, often a hundred, “I’ve written to my MP.” And all that pressure.
Jason Smithson: It was not us as a committee that did this, it was us as a committee that facilitated it, yes. But it was pure way of numbers of members. And I don’t think that’s been done before. Not only was it members who were dentists, it was members who were dental technicians, dental hygienists, therapists, nurses, practise managers, and even patients. That’s what made the difference, I think.
Dominic O’Hoole…: And just to say if we… The fact that it happened so quickly, the fact that within a couple of weeks of starting with over 6,000 members and it just showed you that that massive appetite was there among this big population of private dental professionals that they wanted this voice, they wanted this conduit to be able to speak to people who actually make the decisions. And just briefly going back to that, if we talk about the CDO in England for example, we’ve got to remember, she’s actually been seconded as a deputy commander for PPE procurement. So she’s actually been taken almost out of her role in some ways. There’s a lot of the day-to-day running is done by her deputy. And then we’re starting to hear now that despite initial perceptions, that it wasn’t input from SAGE, which is the government committee that was shrouded in secrecy for a while.
Dominic O’Hoole…: It’s now clear that they do actually facilitate dental specific guidance through the department of health, through NHS in England, to the office of the CDO. And one of my specific concerns here is that there appears to be no dental specific representation on SAGE or its subcommittees whatsoever. Now I can’t be 100% clear about that because despite them yesterday releasing all the member lists, there were certain members decided to remain anonymous. So we haven’t got all the members and then there’s a potential, some theoretical chance that the ones who remained anonymous were dentists or dental professors, or the rest of it. But it seems unlikely to me, and I think that that’s at the heart of this whole thing is that we need somebody, we need people who know about the day-to-day running of dentistry to be providing the centralised advice that we can then get and input into to allow us to go back to doing what we do best. It’s as simple as that.
Payman: Yeah. In some countries, dentists are considered key workers. Over here we… if you look at the Irish exit plan, it looks like… To me it would look like, with the current situation here, we would be coming out at the same time as hairdressers and phase four or phase five tattoo artists. How do we change the agenda over here to make them just like key workers? Why would you… Jason, you travel the world, as far as the respect for dentistry, do you see us as the poor cousin in that sense?
Jason Smithson: To be honest, I don’t have an answer for that. The reality is, in many countries dentistry is seen as a branch of medicine, which is an in a sense essential service. It was not so many years ago in Italy you had to train for medicine and then did dentistry as a sub specialty. And certainly in the UK, Royal College level, for example, dentistry’s still part of the Royal College of Surgeons, et cetera, et cetera. So I really, really can’t give you an answer as to why we are considered separately, and no detriment to hairdressers or anything like that. But we are a subspecialty of medicine and we should be considered so. As to why we’re not, I don’t know,
Payman: But what do we do from the sort of agenda perspective to try and put us up in this… I think in these sort of times, it’s actually a good opportunity to affect that. So is there something we can do now?
Jason Smithson: As a group or our association?
Payman: Well, as a profession. My inkling of it is it’ll take a problem like someone has to die of tooth ache… Something-
Jason Smithson: Well, somebody nearly did, didn’t they? In Exeter quite early on. Somebody was in intensive care in Exter after a dental infection so somebody nearly did. I honestly can’t answer that question. Bertie, do you have any thoughts?
Bertie: I’ll be very honest. For me, that was one of the most shocking things when I came over. Because I graduated in South Africa and worked there for a while, and the level at which dentists are treated as part of the healthcare team was a bit of a shock. Because we were almost at the same level as the milkman, the dentist man, the whatever. It was just so… I sort of looked at it and I thought, “Well, if you treat people at that level and then you hold them to such high standards such as the GDC holds us to, there’s a massive disparity in what’s going on here.” I don’t know how we’re going to solve this. You hear the CDO saying things like, “We’re putting dentistry back in the mother.” I think she meant the mouth back in the body. Yeah. How do we go about it? I actually don’t have an answer. It’s a bit of a situation we’re in actually.
Payman: Sometimes you see journalists hassling politicians during that afternoon briefing thing. One side of you says, “Yeah, you should hold them to account.” Because there’s been a lot of lack of transparency, some incompetence of course. It’s a new situation, it’s a difficult situation. And so should we just be leaving people to it or should we be holding their feet to the fire? And my feeling on it is just like, coronavirus was a great time to accelerate the BAPD, coronavirus is a great time to examine the GDC’s role, examine this problem that we’re talking about right now. And it shouldn’t even be a question of elevating or reducing. But my feeling on it is dentists should be allowed to go back to work. Those who don’t want to don’t have to.
Jason Smithson: I think we’re picking up traction in the media as well certainly Yu Chana gave a very good interview on Sky News this morning. Some of you may have seen that. And the message was very, very different. And I thought it was a very respectful interview and very constructive.
Bertie: Yeah. She’s very good actually. Yeah. And the interview was very good as well.
Dominic O’Hoole…: I think it is a golden opportunity in this awful crisis. It’s a golden opportunity for dentists to come together like never before. I think that many of us share the perception that we have a very heavy touch regulator. And I think that we want to reconfigure regulation so that it’s got the right touch. And I think that happens as part of this overall process of rebirth of dentistry in the UK. And I think that the regulators should be thinking, “We are being looked at now.” That’s a perfectly reasonable thing for us to do because I think that the first contacts we had from the GDC after this COVID crisis started, was a little missive telling us that they were… Just not to worry about them because they were all working from home.
Dominic O’Hoole…: And from my point of view, partially set the precedent that, “I’m sorry, you’re not really speaking for the profession.” And that could very well say, “Well yes, but why the regulators and why not really.” You know but, no, it doesn’t work like that. I think one of the things I’ll be looking for is a GDC that’s by dentists for dentists. So that wet finger dentists are integral and central to the regulatory process for dentists in the U.K. And I’ll leave it at that.
Jason Smithson: I think I would add to that for the dental profession, not just for dentists but everybody within the dental profession, because I think everybody’s in the same boat. There are enough or more dental nurses with issues. Were you? I didn’t notice
Bertie: I’m proud of your Dom, I like the way you put that.
Dominic O’Hoole…: Thank you.
Bertie: Especially that… And I agree with you about the first missive we received from the GDC, it was all about them. It had nothing to do with the profession, with protecting patients, with looking after the people that regulate it was, “We’re working safely from home.” It may not have been what they intended, but that’s certainly what came across to us.
Dominic O’Hoole…: Absolutely.
Prav: Just going back to the media. And stuff that’s been out to the media the various dentists have been interviewed. Some have said things that are so negative about the profession and alluded to the fact that it’s a little bit dangerous to step into a dental practise. Now they are going to be dentists who are probably watching this who may get invited to speak to the media and I’ve never sat up in front of the media, had a camera in my face and all the pressure of that and within 30 seconds had to say anything you can slip up. Now I guess what I’m asking you guys is if somebody does get invited to speak to the press about COVID and dentistry, what sort of message should they be putting out there? And what tone of voice should they be speaking? And if you were to advise them or brief them five minutes before they goon in front of the camera.
Jason Smithson: My first message would be if you’re not confident to speak in front of the media and give the message that you’ve clearly thought out in your own head some hours before or even some days before and prepared carefully because this is an important issue, then perhaps you shouldn’t be speaking to the media and perhaps you should contact somebody who is confident to speak to the media. That will be my first message because it can be very alarming for dentists and patients. Bertie.
Bertie: Yeah, I agree. I think you’ve got to be prepared and Prav you’re right, the pressure is probably… It’s unbelievable. Again, you might prepare in your mind exactly what you want to say, and even they might even give you the questions ahead of time, but sometimes they’ll phrase something slightly differently which can throw you. But Jason is right, you need to prepare yourself. You need to be really well prepared. And don’t wait until you maybe get a call to do something or say something. Prepare yourself well ahead of time as to what you would say. You’re watching other people saying things and you may be thinking, “Oh shouldn’t have said that.” How would you have responded in that situation? So take great, great care and sometimes as much as we all would like our little 15 seconds of fame, if the right thing to do, might be to pass it onto someone who’s going to do a really good job with it.
Prav: I think that’s probably the best advice, because I think especially a lot of dentists feel a little bit… Get this celebrity type persona on them and think, “Wow, I’ve been invited by the press, this is my 15 seconds of fame” or whatever it is. Get a bit star struck and whatnot. And I think that’s right, Is that if you’re not confident at doing it, especially during these times, probably the best advice is don’t do it, pass it on.
Jason Smithson: It could. It could even be something as basic as a patient calling you for some advice. It doesn’t even have to be the media, but you have to give the correct evidence-base message and not spread alarm. That’s the important thing.
Payman: One thing I would say guys is that a week ago, the evidence-based… Now Dominic has found, wasn’t there and
Dominic O’Hoole…: I just like to say that I think that… Just alluding to what both Bertie and Jason said, I think that it’s very easy to go rogue when you’re in front of the camera. Very easy for the rabbits in the headlights. You’re brain disconnects from your mouth and you basically say somethings that you’d never possibly say if you’d actually had the opportunity to reflect beforehand, and you say things that are inappropriate. And I feel great empathy with individuals where that has happened, I really do. What I would say though is that I think sometimes it’s important, with hindsight, that you’re then able to put your hand up and apologise in a very, very non-ambiguous way. When you see that you have actually created a damaging perception within the profession and within patients. And I think that that’s something that I would have liked to have seen in certain cases that I’m thinking about at the moment.
Payman: Going forward guys, what are the silver linings of the situation? We were discussing more use of rubber dam for instance.
Bertie: I think it’s brilliant. I think we where patients that had a resistance to rubber dam in the past. It’s always easier when you say, “Well, the guidelines say that this is what we should be doing.” And I think it takes away the excuse from a lot of dentists as well that the patients don’t like that kind of thing. So we know that that’s one of the things we’ve recommended. I think our defence organisations would love it if we used rubber dam on most of our procedures where we are actually doing treatment. And this is an opportunity for us to introduce this into our practises and just start using it as a normal part of what we do.
Payman: Jason, do you agree?
Dominic O’Hoole…: I would agree with that.
Jason Smithson: I’d agree entirely with that, Dom.
Dominic O’Hoole…: I was just going to say that the innovation that we’re seeing as well. So for example, something as simple as being able to innovate and get a really effective facial that works well with prismatic loops, how fantastic is that? We went from a situation where people were trying to lodge the old face shield in front of the loops with it sticking out of four or five degree angle and providing no benefit for anybody. So a situation now where you can get certain brands of face shield, I mean Oregon’s a good example where it’s incredibly comfortable to wear and yet you can weigh your 4.5 mark loops and forget that you’ve got the face shield on, how fantastic is that?
Dominic O’Hoole…: This crisis has brought the best of British engineer and excellence into play. And as a profession we’re really designing things that are fantastic. We can see that with 3D printing as well. The 3D printing technology that’s allowed wider bar aspirators attachments that can go on our existing aspirate attempts thing that just people think laterally and we come together and we do something that works super well. And it’s this rapid prototyping thing. We’ve got a crisis so we’re not going to mess about, let’s get it done.
Jason Smithson: It’s very British.
Bertie: I think if we look at it… I’m part of a group called the IDDA International Digital Dental Association or Academy rather. And when you look at the reaction that these guys have had on an international cooperation that’s actually gone on between dentists to try to find solutions, innovative solutions to a number of things. And you think, “Wow, if we were this quick with so many other things, how much more can we actually achieve?” And I think it has been really great in pulling people together. So that’s another silver lining on what’s happened with this.
Payman: Prav, what do you say?
Prav: For me, I think it’s been the digital communication between dentists and patients and we’ve broken down lots of barriers. So I’ve noticed now in my practise as we started doing live video triaged consultations and then we’re having conversations with our teams where we say, “Hold on a minute we’d usually get this patient here to have a chat about their treatment plan, we could just do it over a video at their convenience in an evening or whatever.” So I think the thing about doing this sort of stuff, a lot of people find talking to a camera uncomfortable. But I think Zoom and stuff like that has just broken those barriers down with the kids doing fitness classes over Zoom, talking to their families, communicating with their grandparents. So now suggesting to a patient, “Well, let’s do a video consultation or a video call and save an appointment,” I think those barriers have been broken down and I think that’s a big silver lining that’s come out with this.
Payman: I think Jason, you’ve had some successful webinars going on. Do we perceive now that the dental population is going to come in more educated than before?
Jason Smithson: Well, it’s encouraging to see that people have spent their spare time, firstly doing dental education, which is great and, but also maybe connecting with their families, doing a bit more exercise and maybe sitting back and, myself included in this, and looking at actually what you were doing with your life precovid. Perhaps it wasn’t quite the right direction, certainly for me it wasn’t. And there is-
Payman: Finding a more balanced perspective
Jason Smithson: Absolutely. I was looking at, I’ve spent so much more time with my… I’ve spent all my time with my family, which has been amazing. And how we can work forward in the future to maybe do that. Obviously I won’t be able to spend 24/7 with my family, but more time with my family. How I could take more exercise. And I’m sure everybody else is in much the same boat, not only dental education, but all facets of your life really.
Prav: Jason do you think online education is here to stay? Would that be part of your ongoing curriculum considering]-
Jason Smithson: It certainly is for us. Yeah. I think the convenience for dentists of… Well let’s say this, the normal format for most whatever educational programming in whatever sphere is, you sit and listen to a lecture and then sometimes you do a bit of hands on. I think I would hate to see conferences go, to be honest, because I think that has a huge social aspect. It’s not only the conference and the learning, it’s the lunch and it’s the party afterwards. And even if there’s not a party, there’s going for a beer or whatever with the people afterwards, and it’s social interaction. I’d hate to think we were all sat in our little boxes looking at our screens. That would just be weird.
Jason Smithson: But I think you can certainly dynamize your education business by perhaps doing quite a bit of it online and then either the hands on courses are shorter which impacts overheads and makes it cheaper for people or you do more hands on in the same amount of time rather than doing the education, so I think there’s quite a lot to be said for that. So yeah, that’s kind of where we are. But yeah, I’d still like to see a big congresses going. I think it’s very social.
Payman: I’m going to ask the three guests, what’s your estimate of when are you going to get back into your surgery date? When are you going-
Jason Smithson: 9:00 AM at…
Payman: When’s going to do hands on course and when’s the next time we’re going to be able to hug each other again?
Jason Smithson: Oh, I’m not sure I want to hug you at all, Payman.
Payman: Dom, go ahead. What do you think?
Dominic O’Hoole…: Well I think that I’d like to think that by June we’ll have a phaser turn into general practise.
Payman: 1st of June?
Bertie: I agree with them. I think I’d really like to see us by beginning of June that we are… Actually, I’m of the opinion that by the middle of next week we should be able to start seeing emergency patients-
Payman: When will we is the question.
Payman: When will we not, when should we?
Bertie: June. Definitely. That’s me. Yeah.
Jason Smithson: Because the cogs are very big and turn very slowly. That’s the problem.
Payman: Are you saying 1st of June as well, Jason?
Jason Smithson: Is 1st of June a Monday? If it were a Sunday, I would say no. I haven’t got a calendar at hand. So I would say early June. I would hope
Payman: How long before we can do hands on courses?
Jason Smithson: Well I have a council call scheduled for mid June and I have up to now no intention of cancelling it because my feeling is if the government stance is if hotels are opening and the course is being run in a hotel, why would you not do a hands on if somebody is sitting in a restaurant, why would you not do hands on it with correct social distancing?
Bertie: And with people who know what to do.
Jason Smithson: Yeah, exactly.
Payman: Providing PPE masks at the hands on.
Jason Smithson: No. But we will be providing rubber dam.
Payman: So do we have to wait for a vaccine before we can hug again?
Dominic O’Hoole…: No, I don’t think so. I think that that’s a false premise. I think that it depends a little bit on the testing with regards to the massive subset of the population who may have had asymptomatic infection. So studies are very variable on this at the moment. Anything from between 15% and 80% of the study cohort had had an asymptomatic infection. So I wouldn’t like to predict what the actual answer to that is, but there seems to be a consensus developing that it can be an excessive 50% so you can tap find that you’ve got many, many factors of times higher number of people in the population that had this infection than the ones that are reported. I think that creates a background kind of hard immunity situation. I think the second thing is, we have to be a little bit more logical and a little bit more calm about what kind of immunity we’re going to get.
Dominic O’Hoole…: Even if we find that the immunity does weigh in after a year or so, that doesn’t mean that we’re going to get a second COVID-19 infection with the same level of morbidity that we got the first time. A lot of scientific evidence suggests now that even if we did have that situation, that the second time we get the infection it’d be very, very different, sub-clinical almost. And so, I think we’ve got to inject a little bit of optimism into the situation at the moment. I’m very optimistic about it. I think as a civilization, as the human race, we are incredibly resilient people and I think that we will, we will achieve an outcome. There is some of the darkest moments we’ve seen in recent weeks we could never have imagined. But I’m very optimistic.
Payman: I think after the 1914 to ’18 war, then the pandemic in ’18 to ’20 was it, and then the roaring 20s after that. So back then without any of the stuff that we’ve got and then the great depression after that. So yeah, I think there is cause for optimism. Hopefully our businesses can survive this. I want to thank you guys. I think on Friday we’re having a panel of one dentist from each country to see what each of the other countries are like and what those dentists are going to actually say in practise about what their life is like, what the government’s doing, and bearing in mind the different positions of the virus and there’s different times. But I really want to publicly thank you guys for giving so much to the profession.
Prav: Thank you guys, so much.
Payman: All right guys. Thank you so, so much.
Prav: Thank you guys. Thanks a lot.
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.
Prav: Are we all done?
Jason Smithson: It seems so. That went quite well actually. Are you’re happy?
Dominic O’Hoole…: Bloody hell
Jason Smithson: Go on, Dom. Go on.
Bertie: You know you want to.
Jason Smithson: Not one bleep, amazing.
Dominic O’Hoole…: The bloody fagots were chewing me balls all the way
Payman: I’ll stick that in the outtakes, Dom. We’re still recording mate.
Dominic O’Hoole…: Don’t mind I’ve got no shame.