Dentistry can only be delivered with dental nurses at chairside for all clinicians if the profession is to find a workable way forward amid the COVID-19 crisis.

That’s according to Pandora Dental, a pioneering group of 150 independent dental surgeons, who have joined forces with a number of other dental groups to get dentists back to work safely.

These include the IndepenDent Practice Owners UK, as well as expressed support from Alpha Omega and The Portman Group.

More than 650 practice owners, representing more than 1,100 dental practices, have developed what they feel is a better way to deliver dentistry to patients as the government eases lockdown restrictions.

They say four-handed dentistry is the safest way to offer dental care – and mooted that COVID-19 testing before teams return to work may be an option.

Pandora Dental wants to offer dental care to patients who have been denied the opportunity for appointments since dentists were forced to close their doors in March.

Amid a demoralised profession, with 27% revealing they were highly likely to leave dentistry, dentists and their teams must now work together to plug the gap between public perception of risk and the reality, they say.

These were some of the conclusions drawn in a discussion about a new protocol to allow dental professionals to return to work sooner rather than later.

The dental surgeons of Pandora Dental have spent the past six weeks of lockdown researching pioneering technologies and materials, and pooling resources to create a pathway that mitigates a 0.1% risk of cross infection to patients.

They are advocating that all dental surgeries adhering to their carefully constructed protocol should be able to safely and confidently open to patients.

Dr Mark Cronshaw, President of Pandora Dental, is planning on opening the doors of his practice on 1 June with ‘a soft start before ramping it up to increased activity’.

With morale in the profession at rock bottom, he said that the group wants to ensure ‘we rapidly get back to doing what we do best’ as they are ‘concerned for patient welfare and want to get back to work as quickly as we reasonably can’.

He explains: ‘We are faced with an unprecedented challenge in the dental profession. As dentists, our primary aim is to help and treat patients in need, and we find ourselves unable to perform this function.

'Pandora Dental wants to ensure dentistry is accessible to all those who have a need. We have extensively researched best practice and clean air technologies available around the globe to create what we believe is a gold standard protocol for dental practices to open safely during this COVID-19 pandemic and beyond.

'The protocol delivers an incredibly low risk of cross infection to patients and is the way forward for dentistry in this time.’

He added: ‘This is an unprecedented period of national crisis and we are conscious of the demands on the NHS. However, now is the time to pull together and get back to work and reduce pressures on the health service.

'I also believe it is not possible for a hygienist to control aerosol-generating procedures while working as a single-handed operator and, as part of the standard operating procedures, four-handed dentistry ought to be a requirement.'

Part of the challenge of going back to work, they suggest, is also an education issue.

Dentist Mike Lewis, who is a professor at Cardiff University and currently works at the emergency clinic at University Hospital of Wales Dental Hospital, agrees that there a strong education programme is needed – both for the profession and the public and that Pandora Dental already has people writing protocols as well as training and education packages.

Whilst it is understandable there will be anxieties, Mark Cronshaw suggested that education is vital to waylay these fears and show that clinical practice in the current climate is acceptable.

He saw no issues about patient attendance and revealed that he already had a waiting list of people at his own practice eager to get back in the chair.

He also saw no need to limit any procedures and suggested a wellness check every day may be helpful.

A survey conducted by Pandora amongst 5,500 dental professionals (released in early May 2020) revealed that a quarter of all dentists are planning to leave the profession as a result of concerns, been exacerbated by the COVID-19 crisis.

These includes stress, money required for new protocols and PPE and limits on the treatments they can carry out.

If these concerns are not addressed immediately, there will be far fewer dentists left to treat people once practices are allowed to open, they suggested.

Dr Cronshaw added: ‘In a recent survey of our members, it was found that each of us received between two to four patient calls a day who are asking for emergency dental care which would require us to direct them to a UDC. There are 35,000 registered dentists in the UK, and if the pattern we have found is true throughout all our colleagues that means between 70,000-140,000 patients a day are in need of urgent dental care which we are unable to give them – nor will we be able to for some time.

‘As a profession, we are keen to help all our patients and feel that the pathway we have mapped out is clearest means by which we can achieve this safely and effectively. We are seeking an urgent review of any proposed restrictions to dental treatment options and are speaking to the Health Minister Matt Hancock and other MPs as well as all the health regulatory bodies.’

Pandora Dental’s Cross Infection Protocol which mitigates a 0.1% risk consists of:

PPE

All dental professionals working in practice to wear appropriate levels of PPE. A survey conducted by Pandora Dental amongst 5,500 dental professionals shows only 7.4% experienced COVID-19 symptoms prior to the lockdown, which is much lower than the general population, and can be attributed to their use of PPE.

Clean the mouth

All patients to use an anti-microbial mouthwash which is 99.999% effective at killing coronaviruses as soon as they enter the dental practice.

Clean the air

All dental waiting rooms and dental surgeries are to be fitted with Radic8 clean air systems. These systems were developed in South Korea in 2004 in response to the SARS outbreak. They have been proven to kill coronaviruses in the air, and ensure that airborne, droplet viruses, such as COVID-19 are neutralised before they are inhaled. The systems are currently used on all South Korean COVID-19 wards. This pioneering technology is used widely in clinics Worldwide, and the typical time to completely change the air in a room is five minutes (around 25 minutes shorter that the ‘open window’ practice used by the UDC’s meaning significantly more patients can be safely treated in a day).

Clean the consulting room and equipment

All dental practices are already required to thoroughly clean the consulting room and sterilise equipment between patients and sufficient time is allowed between patients to ensure this is conducted effectively. Many practices are also installing the anti-viral clean air systems.

Clean the water supply

It is also being recommended that hypochlorous acid (which is anti-viral and anti-bacterial) is added to the water supply used in the consulting rooms. This is an agent widely used in the food industry and it is non-toxic to people, although highly effective against pathogens.

Minimise droplet release in the mouth

Pandora recommend rubber dam treatment is used for every patient, even for routine dental check-ups.

Reduce any infection laden aerosol spray which is released

When working on teeth, as well as in essential hygiene therapy, there are many aerosol generating procedures where the air can become laden with spray. As this can be contaminated with blood and saliva which has led to the recommendation to stop this type of procedure. However, practices have a range of options available to deal with this problem to the extent that 99.9% of the potentially hazardous materials are safely removed. Stopping dentists and hygienists from providing these types of treatments may result in the unnecessary loss of many teeth, plus there are very many associated serious complications and concerns for the patients’ welfare which could result.

For more, visit http://pandoradental.org.uk

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