COVID-19 & Scottish Dentistry: Where are we now?

Tamika and Darth Pearse

With COVID guidelines changing (what feels like) every day we appreciate it’s very hard to keep up with where things stand with regards to the provision of dentistry in Scotland. So, I thought I’d write some answers to some of the most commonly asked questions we’re receiving in the hope it makes things a bit clearer for you all. As always, though, if you have any additional questions please do not hesitate to get in touch by the usual means.

When is the dentist re-opening?

Hannigan Dental Care is now (and has been since June) open again, albeit with slightly altered opening times for the time being. Our temporary opening hours are 9am – 5.30pm Monday to Thursday and 9am – 1pm on a Friday. Due to additional decontamination measures introduced as a result of COVID protocols, we need to allow staff more time to set up and clean down every day which is why we are currently unable to offer early morning and late-night appointments as we did previously. We have every intention of reviving the popular early morning/late night slots once we’re allowed to return to normal practice as we fully appreciate how popular they were.

What is an AGP?

AGPs are conducted in dentistry it produces an aerosol (a mixture of the patient’s saliva and the water from e.g. our drill) that is expelled into the air. This is why you would have always previously seen your dentist wearing e.g. a visor/mask etc., to stop the aerosol going onto their face. If the patient’s saliva is contaminated with coronavirus, however, it means the aerosol generated is also contaminated with coronavirus and could potentially be transmitted to others in the room. The droplets in the aerosol are so tiny they are often invisible to the naked eye but this means they could be transmitted to others in a number of different ways, e.g. inhaled, direct contact with the eye or an open mouth, or the droplets could land on someone’s clothes or surfaces which are then touched and the virus is transmitted via the hands. Now it is important to note that in this scenario the people that are at risk is the staff, If you’ve heard dentistry being discussed on the news in relation to COVID-19 then you’re probably familiar with the term AGP, but what does it actually mean? Well, the main reason dentistry has been so heavily restricted by COVID regulations is because most of what we do all day can be classified as AGPs – Aerosol Generating Procedures. Obviously COVID-19 is a relatively new disease and our knowledge and understanding of how it is transmitted is still evolving, but experts believe that there is theoretically a higher potential for the virus to be spread via aerosol than by any other modality and whilst this theory is investigated further the decision was made for AGPs in dentistry to be suspended. Unfortunately, a lot of every day dentistry falls under the umbrella of AGPs but namely: anything we need to use the drill for; anything that produces a spray of water; and even the use of our ‘3 in 1’ (the tool we use to dry teeth of saliva so we can examine them). Consequently, the following treatments are all considered AGPs: fillings, root treatments, crown, bridge, veneers, scale & polish and even check-ups (you need to be able to dry the teeth to be able to examine them). Basically, the only dentistry that isn’t considered an AGP is extractions and denture work, so by preventing us from delivering AGPs in practice we were massively restricted in what services we could offer.

The reason AGPs are potentially so problematic in dentistry is if a patient had COVID-19, their saliva would contain infectious viral particles. Normally when not the patient (as they already have COVID) and that dentistry was shut down not because it was deemed particularly dangerous for patients but because it was initially unclear how to protect staff from the risks.

Whilst attempts were made to determine how staff could safely return to work, AGPs were completely banned in all dental practices. This ban has only recently been lifted and we are now allowed to conduct AGPs on NHS patients for emergencies only (i.e. to start a root canal treatment if someone is in extreme pain). However, the profession has had to implement A LOT of changes to the way we provide AGPs to try and mitigate the risk to staff. One of the main changes you will notice is the increased PPE (Personal Protective Equipment) we need to wear. For non-AGPs you will notice all staff will wear their scrubs, wipeable plastic shoes, disposable gloves, a disposable plastic apron, a fluid-resistant mask and a visor. However, if we need to perform an AGP, in addition to the uniform described above staff now also need to wear a full surgical gown over their scrubs, a hair cover, and what is called an FFP3 mask. This is a type of mask which offers a far higher level of filtration than a normal face mask. It also has to be fitted to the individual wearing it to ensure it provides an adequate seal to the face. This is a time-consuming and costly process as everyone has different shaped faces and there are lots of different brands of masks on the market. Staff members often need to try several different types of masks before they find a size and brand that fits them properly and every one of these tests needs to be conducted by someone trained and certified in fit testing. They also make us look a bit like Darth Vader as an aside (see attractive photo), so apologies for that!

Another problem surrounding AGPs is it is still unclear how long any aerosol generated by dentistry could ‘linger’ in the air and potentially contaminate someone else who later enters the surgery. As such, a new concept in dentistry called ‘a fallow period’ has been introduced. This means after an AGP has been completed everyone needs to leave the room and the room is sealed, forbidding anyone else from entering the room for a specified period of time. At the time of writing the accepted fallow period in dentistry was 1 hour, although this could be reduced slightly if the surgery is equipped with a mechanical ventilation and air filtration system. So, if you attend for an AGP now you will not only notice the staff look a bit different but the surgery will probably sound a bit different too due to the air filtration (and the noise of the traffic on Station Road as we have to leave all the windows open too!). The biggest issue with the fallow period having been introduced, however, is it massively reduces the number of patients we are able to treat in a day.

What treatment can I get done now?

So, this is where it gets a bit more confusing…bear with me. Currently, NHS dentistry is in ‘phase 3’ of our return to normal practice. This means we are allowed to treat dental emergencies and provide a limited range of routine services. We are now allowed to offer AGPs in practice (whereas previously they had to be referred out to the Urgent Care Hubs) but still only for emergencies. So, at present, if you wish treatment on the NHS we are essentially still restricted to offering emergency appointments only e.g. extractions, starting a root canal treatment, placing temporary filling material or re-cementing loose crowns/bridges etc. At present, you are still unable to attend for ‘routine’ treatment such as fillings, check-ups or cleans etc.

The health boards have given us strict guidelines which we need to abide by if providing NHS dentistry, and this is partly why Scottish practices are so limited in the NHS services they can provide. For example, most practices have only been allowed to open 1 surgery so as to minimise foot fall through the building and facilitate social distancing. We have also been advised to limit the number of patients we treat in a day to 10 people, partly to help with social distancing but also because we are only being supplied with enough PPE to treat a maximum of 10 patients per day. We have also been advised we are not allowed to charge any patients for NHS treatment at the time being, which is a major obstacle in being able to provide e.g. dentures or crowns/bridges/veneers etc., all treatments which incur a lab fee, as we cannot pay the laboratory for making the device if the patient is not allowed to pay for it.

These rules, however, only apply to NHS dentistry. The health boards are not allowed to dictate how private dentistry is provided, which means that we are now able to offer our full range of normal dental services but only on a private basis.

But Nicola Sturgeon said normal services could resume, so why can’t I book in for a check-up?

Several weeks ago, Nicola Sturgeon did make an announcement to Parliament that normal services could resume in dentistry, but failed to elaborate on what this actually meant. Because it was quite a vague statement it led to a lot of confusion amongst patients who, somewhat understandably, thought it meant they would be able to start attending for check-ups or cleans or to get their outstanding treatment completed. Prior to Nicola making the announcement, we had been limited to seeing emergencies only and referring any emergency AGPs (i.e. if someone wanted a root canal started because they were in pain but didn’t want their tooth extracted) to the Hubs. After the announcement we were allowed to start offering AGPs again in practice, but still for emergencies only. The announcement meant we were also allowed to start offering face-to-face appointments for what were described as ‘oral health checks’ rather than check-ups, i.e. if you were having a problem that you wanted the dentist’s opinion on he/she was now allowed to review it for you.

We are still unable to offer NHS check-ups though for a number of reasons. Firstly, in order for us to be able to examine teeth we need to be able to see them properly, and in order for us to see teeth in detail we need them to be dry. Therein lies the first problem in that we are not allowed to dry the teeth because the use of air is considered an AGP. Furthermore, check-ups at present are fairly pointless because even if we could examine patients and tell them what they need done we are not allowed to then carry out any of the treatment they require on the NHS. Furthermore, we still don’t know when the restrictions will be lifted and it is very possible that by the time they are dental disease could have deteriorated further, meaning the treatment plan has changed and a new check-up is required anyway. Following on from this, we are also unable to consent any one for treatment at present as the NHS has removed the list of services we were previously allowed to provide and also the fees we could charge for providing them. There is no certainty that when restrictions are lifted that NHS dentistry will return to its previous format nor that the same range of services will still be available, so we cannot issue patients with an NHS treatment plan/estimate as we do not know if they will be able to get the treatment they need on the NHS or if they can what it is going to cost.

Another reason practices are not offering check-ups on the NHS is because, as previously mentioned, we are only being provided with enough PPE to see a maximum of 10 patients per day. You will probably have seen in the news that PPE supplies in the UK are already scarce so practices need to prioritise emergency patients and use their daily PPE allowance to treat these first. Dental practices will have thousands of patients registered to them and a busy 3 or 4 surgery practice could easily have been seeing over 100 patients a day prior to lock down, so as you can imagine there is also no fair way to ‘open the flood gates’ and start offering check-ups when you could only see maybe 1 or 2 a day.

Why can I get my treatment done privately when ‘it’s too dangerous’ to get it done on the NHS?

So this is a really common misinterpretation. When I read the comments on news articles about Scottish dentistry just now there is a lot of anger amongst the general public. People are quite vocal about their dissatisfaction with dentists and many feel like they’re being exploited, that dentists are capitalising on the pandemic and seizing the opportunity to make a fast buck. Let me assure everyone reading that this truly is not the case.

Firstly, the risk of any given procedure is exactly the same to the dental staff regardless of whether it is provided on the NHS or privately. However, certain treatments do require enhanced PPE (as previously discussed) and this comes with a cost. At present, the NHS simply cannot afford to provide dental practices with the amount of PPE they would require to see the number of patients we normally do. They also have to prioritise their limited resources and so, understandably, front line staff working in hospitals and fighting COVID-19 get the majority of the PPE supplies. Private dentistry however, is completely independent of the NHS, which means the practice has to buy in their own PPE. So, a practice that doesn’t have enough NHS PPE to see the patient on the NHS may be able to treat that same patient privately if they use their own supply of PPE. Now I’m sure a lot of you are thinking ‘aw, a mask only costs a couple of quid, why can’t those tight dentists just use their private PPE for NHS patients?’. Well it’s because the level of PPE we are required to wear (please see above) is a LOT more than just a paper mask. The cost of single-use surgical gowns, hair nets, FFP3 masks etc. adds up to approx. £40 per patient (remember the dental nurse has to wear it all too, not just the dentist) so Practices simply cannot afford to take on the debt when we are still not allowed to charge NHS patients.

Most importantly, however, the reason why you can currently get treatment privately but not on the NHS is entirely to do with the restrictions enforced on us by the NHS health boards. The NHS have literally forbid us from delivering the vast majority of routine services for the time being, but they cannot dictate what we offer privately so many practices are simply continuing to offer the private treatments (same as they did before lock down) and it’s up to the patient whether they wish to pay privately or wait for NHS services to resume.

What can I get done privately?

At Hannigan Dental Care we are back to offering our full range of private treatments, same as pre-COVID. This includes all aspects of dentistry, including cosmetic dentistry, Invisalign, Cfast, implants, hygiene services and facial aesthetics. These services are available to all of our patients: if you are a Denplan patient they may already be covered by the cost of your monthly plan; if you are an NHS patient you can opt to pay privately for a specific treatment and still retain your NHS registration.

When will I be able to get booked back in for NHS treatment?

The honest answer is we don’t know. The Scottish Government are playing their cards very close to their chest with regards to plans for our future and at this point we genuinely know little more than you do. Obviously with COVID cases starting to rise again there are fears that we may go in to another lock down over winter and this would obviously set things back further. Conversely, if cases improve dentistry may return to normal quicker than we anticipate. I suspect a lot of the lack of communication from ‘the powers that be’ is simply down to the fact that they genuinely don’t know either and are just having to wait and see if, when and how badly this second wave hits.

As things stand, the dental profession has not been given a date when current restrictions will be lifted. What we have been told is that it is unlikely to be before Scotland progresses to Phase 4 of the route map, i.e. until a vaccine is in general circulation. The rumours going round (albeit unsubstantiated I should mention) is that current restrictions could be in place until next year. So, whilst we are not trying to panic anyone people do need to appreciate NHS dentistry as we knew it is unlikely to return in the near future. Additionally, we need you to appreciate that all dentists now have a back log of work dating back to March which is growing bigger with every week that passes, so even when restrictions are finally lifted you are not going to be able to phone and get booked in for an appointment the next week. Waiting times for appointments are going to be very lengthy and it may well be months before you will be able to get an appointment even after restrictions are lifted. I appreciate this sounds bleak to say the least but sadly this is the reality we are facing.

Why aren’t all practices offering the same things?

This is also causing a lot of confusion amongst patients as some practices are open full time whilst others have only re-opened part time. Some are offering AGPs, some are not. Some are offering treatment privately, others are not. Patients feel like they are being deceived if they are being told one thing by their dentist but their pal is getting told something else at the practice down the road. The reality is nobody is lying or shirking their responsibility but different practices will choose to run their business differently. So, at Hannigan Dental Care we have chosen to re-open full time because we are offering private treatments as well as continuing to see our NHS patients for emergencies. Other practices have chosen not to offer private treatments, so they see no point in staying open all day if they are limited to only seeing 10 NHS emergencies per day.

Similarly, at HDC we are offering AGPs both privately and for NHS emergencies. We are able to do so because Pearse (big smarty pants that he is) went on a course during lock down and became certified in fit-testing people for FFP3 masks. This means he can legally test and fit all of our staff for the appropriate PPE meaning everyone can safely work, however the majority of dentists need to employ someone to come out and do this for them. Prior to the pandemic there wasn’t a huge demand for this service (it was mostly for builders on work sites removing asbestos etc) so the waiting list to get fit-tested is pretty long. Furthermore, the NHS is only supplying practices with a limited range of FFP3 masks so if you are unlucky enough to have a face that doesn’t fit a ‘standard’ size mask you are not allowed to provide AGPs on the NHS. Another reason your practice may be unable to provide AGPs is because of the building itself – if the surgery doesn’t have a window or hasn’t installed an air filtration/ventilation system they won’t be allowed to conduct AGPs at all.

A final reason why some practices are offering differing services is down to the staff itself. Because we are unable to socially distance from our patients, because we are literally working in the most infectious part of the body, because we deal with AGPs dentistry has been classed as a ‘high risk profession’ so some dentists or nurses may not be allowed to work due to underlying health problems or because of pregnancy. In some cases, this may have halved the work force so the practice simply may not have enough staff to open fully. Additionally, self-isolating rules can massively impact on the work force. With families now getting asked to isolate for 2 weeks if there has been a positive case in schools/nurseries etc., practices are facing staff shortages on a regular basis. Dentistry simply doesn’t work if you are short staffed so practices may have to temporarily close from time to time for this reason alone.

I got referred months ago and I’ve still not heard anything yet?

Outpatient clinics for dental appointments (same as doctor appointments) all got cancelled during lock down. Whilst some clinics are now gradually restarting, social distancing requirements means they are not able to operate at full capacity and waiting times are very lengthy as a result. Some services, deemed non-urgent, have been benched completely for the time being so that resources can be targeted at more urgent services so depending on what your referral was for it may still be some time yet before you receive an appointment and unfortunately there is nothing we can do about this.

On a more positive note, during COVID the NHS did try its best to prioritise cancer patients and so the Oral & Maxillofacial Surgeons (the team that treat mouth cancers) continued to work pretty much as normal throughout the pandemic. They are still accepting referrals and are still committed to reviewing suspected mouth cancers within their 2-week target so if you have noticed a new lump, red/white patch or ulcer in your mouth or lip, that has not healed after 2 weeks please make an appointment at your dentist to have it assessed. Review of a suspicious lesion DOES warrant an emergency appointment and we will make sure you are seen quickly.

Another big problem for referrals has been children waiting on extractions under GA at hospital. Many children had their appointments cancelled during lock down and the waiting times for this service was already months long so we fully appreciate how frustrating it is for parents waiting on this service resuming. A GA list has now resumed but again it is not running at full capacity as of yet. If you feel your child is getting worse, i.e. they are no longer able to manage their pain effectively with analgesia or they are persistently getting swellings/infections despite multiple courses of antibiotics, please do get back in touch with us and we will endeavour to do whatever we can to get your child out of pain.

Can I register as a new patient?

We’ve had a lot of patients contacting the practice over the past few months asking if they can register with us. Unfortunately, we are unable to register any new patients on the NHS at the moment. The reason being you are not allowed to register a patient on the NHS without having carried out a full check-up on them first. Due to COVID restrictions (as previously explained) we are unable to offer check-ups at the moment so we cannot officially register anyone as a new patient. However, reception can take your details and add you to our waiting list so please do get in touch if you wish to register and we will be in contact with you as and when things get back to normal!

Alternatively, you can choose to register at the practice as a private patient if you wish to be seen sooner. There are different ways to do this but essentially you can either pay as you go, or you can join one of our Denplans and spread the cost each month. Details of all the private plans we have available can be found on the website but please feel free to contact reception if you would like to discuss anything further.

Why is the media talking about dentistry potentially collapsing?

So, what many people do not realise is that all dental practices are privately-owned small businesses. We are not run by the NHS, the NHS do not pay for our premises, our overheads or materials, nor do they pay us or our staff. Dentists are self-employed and can elect to work as a contractor for the NHS, in which case the NHS will pay them a fee for services provided. We essentially work on commission so we only get paid by the NHS for the work we do, but if there is a global pandemic that shuts down your practice meaning you can’t work for months you can’t generate any income. Unfortunately, practice owners, same as any other business owners, still had outgoings that needed to be paid – business loans, rent, utilities, wages for their associate dentists, dental nurses, hygienists, etc. so at the start of lock down the Scottish Government had to step in with a rescue deal otherwise all dental practices in Scotland were facing bankruptcy. The deal that was negotiated provided practices with a proportion of the NHS earnings they would have normally grossed, but also meant practices were not allowed to avail of the furlough scheme for their employees. For practices that were purely private, there was no help and so the threat of bankruptcy in the private sector was very real. Even now we have been allowed to re-open, finances are still very uncertain for dental practices: we have had to massively reduce the number of patients we are allowed to treat each day, we are not allowed to charge patients for NHS treatment, we are limited in what NHS treatments we can offer, we can’t register new patients, we are having to buy in enhanced PPE which is estimated to have risen in cost by >200%, the list goes on. The NHS is continuing to pay practices these grants each month to ensure that they are able to keep their doors open, but it is at massive expense to the NHS so the media is speculating how much longer it can go on for given how little patients are getting back in return for the public investment. This has led to widespread concerns that NHS dentistry will not return in the same format we previously knew it, although there has been no official confirmation or denial of this by the higher powers.

Hopefully that clarifies a few issues but please don’t be afraid to message me if you there is anything I haven’t covered. As soon as we receive any updates from the Chief Dental Officer I post about them on the Hannigan Dental Care Facebook page so please give us a ‘like’ if you haven’t already so we can keep you all up-to-date on the latest developments.

Keep safe

Hazel Hannigan