The new norm, for as long as it takes: getting out of the (dental) confinement

Somehow, to me, the term used in France, le confinement, seems to describe what we have all been going through appropriately as (other than the meaning that we previously associated it with, namely, deliverance or childbirth), it can be roughly translated to captivity, detention or indeed confinement. The majority of readers of Dental Update are general dentists, so they will not need to be reminded about the profound consequences of the confinement, social distancing and so forth, all of which have prevented the operation of dental practices in the way that we used to consider normal, with the various financial sequelae to that, notwithstanding the inconvenience to, and in some cases suffering by, patients. Despite the mixed up way that the announcement was made, the good news is that a date has been set for the re-opening of dental practices in England.

There is no doubt that the coronavirus is highly contagious and that additional steps, over and above the old norm, now have to be taken and these will necessarily disrupt the throughput of patients. Dentists, however, are adaptable and, to some extent, the profession has been here previously. Before the advent of AIDS and increasing awareness of hepatitis B and C, customary practice was to carry out treatment, including extractions, while not wearing gloves or mask. It was generally only for surgical extractions that gloves were considered desirable – tell me the logic of that! I changed to routine glove wearing when my attention was drawn to a paper published in 1982, results of which indicated that blood products were present under the fingernails of dentists (attending a conference) who had not seen a patient for five days,¹ the inference being that such blood products could readily harbour blood-borne viruses. The cartoon in Figure 1 was drawn in the early days of glove wearing by dentists, when there was significant opposition to the practice. With the arrival of HIV and hepatitis B and C, however, we started taking infection control more seriously, sheathing air and water lines: the photograph in Figure 2 was taken by me in the 1980s when we started doing this. There was no evidence that this would be beneficial to the safety of patients or clinicians, in a similar way that dental surgeries in the UK were closed in March 2020 when there was little or no evidence that they would be a vector for transmission of the coronavirus. At the time of writing, when the easing of the lockdown is proving to be more difficult than its introduction, the re-opening of dental practices seems to be causing great soul-searching. At the time that I alluded to above, when an awareness of HIV and hep B dawned, changing the surgery between patients began to take increased time: no longer could a surgery be changed around with a quick rub with an alcohol wipe (which was probably of little or no value anyway), but the dental team adapted to the new norm then. We realized that the hot air oven was not a sterilizer, and we bought and used autoclaves and changed gloves between patients. Readers will not be surprised to learn that there was no enhancement of NHS fees for the increased time required for the various procedures. The dental team have always been at risk to infections carried by patients, so we used PPE to reduce the risk, although it was not possible to reduce the risk to an absolute zero. Now is the time for a further adaptation for the dental team, a further stepping up of PPE, although, again, it may never be possible to reduce the risk to zero.

On the other hand, might there be a way that changing clinical techniques might help? Many of the articles in this issue have been specially commissioned to help with this – many thanks are due to the authors who have produced these at short notice. First, taking a COVID-oriented medical history from the patient, perhaps in a phone call prior to their visit, could help identify those patients at risk. The use of rubber dam may help the spread of potentially contaminated aerosol in the environment, given that Samaranayake and co-workers reported that the use of rubber dam reduced up to 70% saliva or blood-borne aerosol particles within a 3-foot distance of the operational field.² Given that a recent survey of UK dentists' behaviour indicated that rubber dam was used for operative dentistry by 31% of respondents to a questionnaire to 500 dentists,³ it looks like there will be a surge in demand. Once the dam has been applied, it also seems sensible to swab the tooth pre-treatment with a sodium hypochlorite solution, such as used for the disinfection of root canals. There might also be a surge in demand for hand scaling instruments, given the demise, for the time being, of the ultrasonic scaler.

I realize that 80% of our readers are general dentists and I, along with them, want to try and facilitate their urgent return to working in their practices. Readers are directed to the opinion piece by Dominic O'Hooley on aerosols and are also directed to the paper by Damien McNee on how dentists are getting back to work across the world. (I am advised by colleagues from Germany that many dentists there did not stop working at all.) Both of these papers are based upon documents originally prepared for the British Association for Private Dentistry. I am also delighted that Professor Samaranayake has offered to keep updating readers, issue by issue, on the progress of COVID-19, in the same way as he did for Dental Update during the AIDS epidemic in the 1980s. His first ‘Commentary’ is in this issue. And, what if we could manage our restorative dentistry without an aerosol, or a reduced aerosol? I, with my excellent co-authors Louis MacKenzie and Peter Sands, have prepared a paper giving suggestions on how this could be achieved. There is some good news from a recent publication.⁴ Only half of the patients seen by NHS dentists required ‘active’ treatment – defined in the paper as restorative or periodontal treatment, while the other half did not require ‘active’ treatment. Surely, as a starting point, it should therefore be possible, when dental practices re-open, to commence carrying out, more or less immediately, non-active treatments such as examinations and other non-invasive treatments? That would be a start.

I hope that the information contained in this issue will be of value to readers, and I fervently hope that, by the time you receive the issue of Dental Update after this one, life will have returned to what I will term the new norm and that we have identified a method of working which does not greatly decrease throughput of patients, without endangering the lives of the dental team and patients alike.