When the patients swan back in -it'll be here before you know it.

Every day I count my blessings.

At least I’m no longer a dental practitioner, and more importantly, I’m not a practice owner. I was probably the most inept dental practice boss in the history of the world and I struggle to get my head around what faces dental bosses and associates when the coronavirus lockdown ends and there’s an orderly/disorderly return to work.

Last week, a prominent dentist I follow on Twitter, Judith Husband, set up a poll. The poll posed the simple, but crucial question:

“When do dental teams think we will be back in surgery doing our routine treatments?”

I’m not naturally an optimist, but I saw a glimmer of hope that so many reasonably sensible and analytical people could come to consensus and a fairly sunny outlook. Of 265 participants, nearly half of them thought that July (2020!!) would be the time normality would return to dentistry. Longer would be a horrible thought, although it depends largely on if the UK population stayed out of the parks over the Easter weekend or had to be dispersed by aerosols from a police riot squad water cannon. 31% thought dental practices wouldn’t be back in operation until October, but I suspect those were mainly those pessimistic practitioners who get the surgical kit out ‘just in case,’ even when they are taking out a grade 3 mobile lower central incisor.

Speaking for myself, it’s been nice having people to play with during the day on Twitter. For the most part, dental professionals have been burdened by the guilt and frustration of not being able to tend to their patients and the financial worries that practice shutdowns have caused. Most dental professionals have been champing at the bit to get their hands back on their turbines, scalers, aspirators and extraction forceps. I assume, similarly, orthodontists are also keen to get back to elastic bands and bits of wire in order to create temporary speech impediments in angst-ridden teenagers during those difficult years of puberty.

But when the day finally does come, and UK dentistry does get back to ‘normal,’ what exactly will be the new normal?

I wrote on Twitter earlier in the week that when I trained in the 80’s, students were working without gloves and even took teeth out with bare hands. It was only if you were doing a surgical extraction that you were allowed to use gloves. Then one day we were told to wear gloves, with no real explanation. A little while later, HIV and AIDS hit the headlines and we suddenly realised why the need for gloves were overnight, de rigueur. Some dentists replied with what would be horror stories if repeated now: Biogel gloves being washed and reused and dentists working without masks or goggles. When I qualified in 1988, I knew of one dentist who was boiling instruments. Admittedly she’d splashed out on a new set of Teflon saucepans when she received a small NHS grant, but really?

The jolt from HIV pushed dentistry into leading the way in cross-infection control. Similarly, the re-emergence of ‘Mad Cow Disease’ (vCJD) in 1993 nudged dentistry into abandoning the practice of reusing endodontic files and the philosophy of ‘single-use only’ took off big time in dentistry.

We are currently experiencing the most significant pandemic since the devastating Spanish Flu in 1918, so what will happen to UK dentistry in the post-SARS-CoV-2 world?

Cross-Infection Control

Frankly I haven’t a clue about changes that may need to be made, so this is all speculation. The opinion of some virologists is that this particular coronavirus isn’t going to go away forever, even if it does bugger off temporarily. The fear is that the virus will return during the winter months and so it will present a persistent challenge for both dentists and medics in keeping spread to a minimum and protecting themselves from infection, even during apparently quiescent periods of COVID-19 activity.

The question is, will dental practitioners go back to using just scrubs, cheap surgical masks and standard goggles for exams and treatments? It seems unlikely, whether by decree or their own choice. Although I felt I had become immune to a lot of bugs going around the longer I was in dentistry, I did feel that the few lurgies I did go down with were probably caught from patients. “Do you remember? Mr Grinstead came in a sneezed at your mouth? You had to go and change your mask.” Ah yes, that rings a bell. The mask fell apart after that assault.

So, I can foresee (as can many on Twitter), that FFP3 masks will become standard wear in dental practice and out will go the flimsy examination masks that made your ears stick out like Dumbo anyway. And of course, that will increase practice costs, but Boris seemed in a magnanimous mood before he became unwell, so I’m sure he and Matt Hancock will ensure practices don’t lose out financially (don’t hold your breath). Just ensure you aren’t wasting it otherwise Matty will be after you and name and shame you at a virtual press conference. And when you DO go back to practice, would you be better off leaving your mask on all the time, even when discussing with a precious mother how little Abigail eats sweet, but not MANY sweets.

And if you are going to use FFP3 masks, they will of course have to be fitted properly for every member of staff, even Brenda, with the collagen fillers that went wildly awry. And if you are going to go FFP3, you will need the visors to go with them, not to mention the concomitant problem of accommodating your surgical loupes underneath when you DO finally get around to doing some precision restoration work.

And are your scrubs alone going to be adequate in protecting you against dormant unknown carriers, or will biohazard suits be essential for the fashionable dentist-around-town?

Dental staff going out of the practice in their scrubs at lunchtimes will have to be absolutely stamped on, and I can see a time when dental nurses will have to remove their scrubs to eat their calorie-free salads, even if they ARE hermetically sealed in a battered Tupperware tray. The staff room biscuit free-for-all will also have to stop. I mean, how would you know for sure if the colleague who opened the biscuits and stuck their mitts in them was not a carrier of the virus? Tragedy. A packet of McVities Chocolate Digestives just dumped in the bin without going near a taste bud? The humanity!

The other thing is, will the nurses have to be disinfected when they leave the surgery to go to the decontamination room? And if they have to pass close to patients on their way to the autoclaves, will the patients have to be sprayed afterwards?

Since there is some growing scientific opinion that the virus is now endemic, there would have to be an assumption that every patient was a carrier of the coronavirus – much like our pre-coronavirus cross-infection controls were based on the assumption that everyone was positive for Hepatitis B. Potentially more time would need to be allotted per patient for screening during the medical history-taking stage and in the clearing up process after the patient has left the surgery. I’m not sure quite how you remove aerosols that might still be gently wafting on the breeze towards the ground, but I would assume this takes time, unless the nurse swings an aspirator with a funnel on the end of it around her head, like she’s Roy Rogers trying to lasso a Mustang in a 1950’s Western.

Also, will pre-treatment antiseptic rinses have to be given as standard before you get within six feet of patients, and more chillingly, will you have to speed up your rubber-dam technique and use them as standard for ALL restorations, let alone root-fillings. Even worse, how about if the authorities banned the use of air scalers and hygienists had to go about their work with things like Gracey Curette’s (is that a thing?) or push scalers. What about if hygienists had to use rubber dam if they DID use air scalers. Gone would be the 20 minute hygienist appointment, forever. But that’s being silly.

Also, will the disposable plastic-backed disposable bib be enough protection for patients? Imaging the viruses clinging to the ceiling strip lighting, waiting to free-fall like Daniel Craig in an opening sequence of James Bond’s latest adventure, into the patient’s awaiting orifices. Will the patient have to be masked up before you are ready to give the local or start the procedure as is currently happening in urgent referral centres?

And if you DO have to use slightly alien PPE, will you have to allot more time in order to coax youngsters into accepting fluoride varnish and convincing them it’s completely harmless despite being dressed like you’ve just been juggling radioactive isotopes.

Coping With The Backlog

Of course when you do get back to work, there will have to be even more triaging to do. There are going to be an enormous number of patients who have been sitting on problems over the lockdown and they will have to be prioritised. Patients mid-RCT, patients who have been temporised, patients waiting for crown fits – the list is endless. Just imaging the over-eruption that’s occurred – it’ll be like Vesuvius. AND the number of bruxists that must have gone into overdrive during the stress of lockdown doesn’t bear thinking about. The number of cusps that must have bitten the dust must be astronomical. Also, Mrs Cholmondsley has been thinking about the denture try-in from last time and she’s decided to go to a shade lighter than the one agreed on. You’ll have to sort her out while explaining to the technicians why your cheque might be a bit late this month.

And since you are going to inevitably have gangs of patients when lockdown ends, will you have to reduce the numbers of patients in your waiting rooms? The papers are full of stories that social distancing will have to carry on till at least the end of the year, so will the nurses have to take it in turns acting as bouncers on the doors in order to prevent Beryl on the reception desk being swamped with hordes of angry viral-laden moaners all at the same time. “I rang the emergency number and it just put me through to 111. I was on the phone for three days!”

Finances

And last, but by no means least, sorting out the money on your return and trying to figure out what you are owed by the NHS and the government, when you are going to get it, and who exactly you need to give it to. Also, budgeting for all the new PPE you’ll need will be a nightmare. I’ll leave that for you to sort out. Not that dentists and practice owners haven’t been frantic with worry about this all through the crisis. It didn’t help that nobody really knew where they were financially in the first couple of weeks an even now, some aspects, particularly surrounding the intricacies of furlough, are hazy.

Nope, I don’t regret giving up practice ownership or wet-fingered dentistry last year, one little bit. My timing was impeccable.

Ugh! Wet fingers! I need to wash my hands now.

“Happy Birthday to you, Happy B…..”

(PS – Get well soon TJ)