SDCEP published another rapid review on 25th September 2020. There was a lot of hype ahead of its release, I may not be over exaggerating if I compared it to the release of a Hollywood blockbuster! It goes to show, that these days, our lives revolve so much around new documents, guidance and guidelines related to dentistry in the pandemic era. In a way it is being nervous of what Facebook language calls FOMO (fear of missing out, for those unfamiliar!)
SDCEP quotes in the opening statement of its rapid review, ‘It is important to stress that this document does not have the status of guidance. It is provided primarily for use by policy makers and those who are developing clinical guidance relevant to dental care delivery during the COVID19 pandemic’.
We are all trained from our days at University to refer to guidelines with quality evidence, in an era of Evidence Based Dentistry. We understand there is not enough time, amid this pandemic, to synthesise evidence via meta analyses or systematic review…we are not in an ideal world!
So much expectation was drummed up in the official communications from the CDO that they will base their further decisions on the findings of this rapid review, for future dental workforce and service planning. I am confused to say the least. I was under the impression SDCEP was meant to give reliable guidance in its well-known format to help CDO. Ball is back in your court dear CDO…!
The SWLG report established by NSS Scotland reported the minimum ventilation requirement based on a document published in 2006. However this was never a mandatory requirement in the years to follow and during routine inspections hardly any emphasis was placed on ventilation, although our operating surgeries are heavily contaminated with variable concentrations of bacteria, viruses and potentially harmful chemicals, within the splatter and aerosol that every power tool creates. I am not even referring to deadly SARS-CoV-2.
SDCEP recommends 10ACH as a standard which will lead to fallow time of 10 mins. I do not quite understand how the magic number was reached and why is it not 15 or 20ACH? What will happen in surgeries with windows, or no windows but with similar ventilation mechanics? SWLG mentioned 20min right?
What is even more puzzling – is 10ACH the minimum requirement that guarantee dental practices against disease transmission on its own accord? Not so sure. Especially when the risk of seeing an asymptomatic Covid +ve patient is about 1:20000. How much viral load is there in an asymptomatic patient and with all the precautions and risk assessments is there a real risk of disease transmission?
Check this table which lays out clearly what is the potential risk of a dental practitioner coming across an asymptomatic patient in Scotland. Almost negligible but still we must follow the precautions, and that is entirely acceptable.
The review also quotes- The role of asymptomatic cases in transmission has also been highlighted as a concern. At the time of writing there have been no confirmed cases of COVID-19 transmission in the literature linked to dental settings despite the potential risk of transmission in such environments….. So what is all the fuss about? Should we just get on with it?
Will there be a new Ventilation grant? Not all practices can have mechanical ventilation of 10ACH and getting to this target will be a considerable challenge. There are multiple hurdles in the process such as size of surgery, location of the practice, adjacent premises and complaints from the occupants of neighbouring properties. Theoretically speaking we are pushing more viruses into the exterior environment in the clearing up of our surgeries during AGPs. How relevant is this?
Also let’s face it , extractor fans push all the heat out and when we hit winter they blow out all warm air, effectively creating arctic conditions for the dental team to work in a safe but freezing environment.
HVE and rubber dam are not new inventions and are probably the main tools in risk reduction. It should not be a big issue optimising the high-volume suction to ensure it does the job.
They are still saying there is no evidence for air purifiers and pre op mouth rinse. It’s a shame that these two methods, used globally to manage risk of Covid transmission, are not being utilised at this stage, and we must now wait for more detailed evidence or studies to see their efficacy established. There was some allowance given to air purifiers in SWLG report and this is completely excluded here. Combined with mechanical ventilation they can increase the air change rate and their potential benefit seems logical.
Since the onset of pandemic and the lockdown of dental practices, this is not the first review published. Most recent reviews have been just reviews. What is hard to fathom is why do we not have analysis of quality of evidence? Whilst I understand the whole saga of the Covid pandemic is filled with uncertainties, unchartered territory for all of us, the expectations of SDCEP are high by default. There should have been a clear classification of evidence, on the basis of quality that we are traditionally used to. This will make it relevant not only to public authorities but also to the dental community, in making safe and appropriate decisions for patient care.
Wearing the hat of a primary care dental professional, it comes across to me as a big anti-climax and waste of precious time and money. We are 6 months plus down the road in this pandemic which seems never ending, and keeping our fingers crossed as to what comes next. Amid this anxiety, we are all overwhelmed by the plethora of government commissioned reviews and guidance.
The other fears expressed by colleagues and friends more informally are - will public health bodies use this review to impose new requirements based on unclear analysis of data, having spent substantial sums of money from its coffers on this rapid review.
It looks like we have more questions than answers. Let us hope for some favourable ruling by our bosses in St. Andrew’s House.