A personal perspective on COVID-19 from an expert witness and specialist in restorative dentistry.
By TOBY TALBOT BDS (Sheff) MSD (Washington) FDS RCS (Eng)
We began to hear of the coronavirus pandemic in Wuhan Province in China in early January 2020.
Rather than wait for formal advice from our authorities, I contacted a colleague working in Hong Kong, who was well acquainted with the effects of the SARS outbreak in 2003, a variant of coronavirus. A similar pandemic of MERS that had followed in the Middle East in 2012 led me to contact colleagues in the Emirates. They kindly passed on the protocols that were adopted by them at that time for me to implement immediately in my own clinic.
A year’s supply of personal protective equipment was ordered, which remained in plentiful supply at that time.
This is a letter that was sent to all our patients:
"Due to the pandemic of COVID-19, our lives have changed. This has particularly affected our protocols when seeing our patients. To minimise the potential transmission of the coronavirus we have adopted the following protocols that now become a long-term feature in how we operate.
When a patient contacts us to arrange an appointment we will ask a number of questions that can be responded to by email or phone before your attendance.
1: What is the problem? When did it start? If you have pain, what score would you give it out of 10 – 0 is no pain, 10 is agony.
2: Do you have any medical history, including the names of any medication.
3: The name of your dentist if this is your first visit to our clinic. When was your last dental visit? Was it for treatment or a general review?
4: Whether you may have had or have symptoms of COVID-19, including a temperature, headache, cold symptoms, a dry cough, loss of smell or general fatigue. If so, when did symptoms start? When did symptoms end? It is to be noted that we will make every effort to delay a visit to our clinic for four weeks after any symptoms have occurred.
5: If you have had a diagnostic test, whether for the antigen or antibody, what were the results? When was the test carried out?
6: Have you come into contact with anyone who was subsequently unwell with the above symptoms or have been diagnosed with the disease? When?
To prepare yourself for your visit to us, we politely request that you wear a mask or face covering. Kindly remain in your car upon arrival. We will come to you with a medical history form to be completed and a review of your symptoms. We will take your temperature. We kindly request that all accompanying persons wait in the car and do not enter the clinic. There will be no waiting area provision within the clinic during this time. If you require a parent or guardian to accompany you, then we will discuss the protocol with you and them.
When you are escorted into the clinic you will place overshoes over your own shoes before entering the clinic and use the hand sanitiser before entry. You will be escorted directly to the prepared surgery. You are respectfully asked not to touch anything upon entry.
Appointments are scheduled with a 30-minute gap before and after your appointed time so that you will not make any close contact with another patient to reduce risks of transmission.
The surgeries have filtered laminar air flow that changes in the room up to 20 times each hour. The surgeries are disinfected before and after your visit. We will be wearing personal protective equipment (PPE) that may seem a trifle distressing, for which we apologise but it is for all of our protection. Gowns, masks and face shields with gloves will feel understandably distancing but essential. Your safety and comfort is our priority."
We had the required scientific information when a formal review of the subject of SARS in 2015 and MERS in 2016 was considered by academics, with their conclusions readily available. In summation, the pandemic indicated quarantining patients affected, isolation of ‘at risk groups’ such as the elderly and those with underlying medical conditions, and amassing a stockpile of PPE for healthcare workers. It also advised the universal wearing of face masks for everyone.
It also concluded that to curtail travelling, especially on public transport systems including trains and air, was advised. Mass meetings of people were cancelled. Subsequent studies have shown that PPE stocks can be kept for over 10 years without deterioration. Acquiring a stock of diagnostics for testing large population groups was indicated, to measure the incidence of the disease and to identify ‘hot spots’.
I have just recently taken a business trip to Jersey in the Channel Islands. We were proactively encouraged to have antigen PCR tests 72 hours before entry; if you failed to do so, a PCR antigen test was carried out upon landing. You would then be effectively ‘confined to barracks’ for 12 hours until the results were texted to your phone.
The entire population were wearing face masks and it was ‘business as usual’ in the shops, bars and restaurants. Before the reader announces how much easier for it is for an island to comply with this protocol – for those who may have forgotten, we are an island.
Politics aside. How do I see the pandemic affecting the expert witness in dentistry?
Dentistry involves drilling teeth with high speed tools that create an aerosol effect. In other words, when we drill teeth the air expelled from the mouth disseminates all the micro-organisms throughout the surgery thus ’spreading’ whatever bacteria and viruses are present throughout the premises. If a patient has had coronavirus, even if blood tests indicate negative with the antigen, the saliva continues to be positive with antigens for four weeks after their recovery.
To contain that effect, high volume changes of the air within a surgery need to be carried out, with filtered laminar air flow directed from ceiling height and out at floor level. That is routinely installed in all operating rooms in hospitals to create a sterile environment.
Advice given to dentists indicates testing themselves for antigens or antibodies for the virus. The former indicates you have the disease; the latter indicates you have had the disease with a possible element of immunity, although that has yet to be scientifically established. I have my staff and myself tested for the antigen on a regular basis.
Now I would like the reader to imagine the dentist attending 30 to 40 patients per day. Does the practice find itself in a green, amber or red zone? What are the demographics of the attending patients? Different age groups in social groups 1 and 2 are more likely to comply with self-isolation and social distancing than social groups 4 and 5 or young adults who like to party at weekends. Or is the practice located in a metropolitan area with larger elements of social deprivation or multi-generational households? Many practices may have several dentists working in the same building.
How is social distancing going to be managed effectively when over 100 patients are coming through a door in a day? Imagine, if that practice is on the high street without its own car parking facilities, how do you control people entering and leaving the premises maintaining social distancing? Does the entrance provide adequate ‘distancing’ in the hallway or on the stairs?
Assuming that a fallow period is assigned between patients to allow for thorough disinfection of the surgeries and premises, how many patients can actually be seen in the day? Productivity is inevitably going to diminish. Will the business remain viable? Will the commercial pressures of maintaining the business lead to an element of compromise? Over time, will there become an element of ‘battle fatigue’, with a lapse of established protocols, or will the ‘new world order’ remain sustainable?
Will the entire national population just drift into a state of herd immunity for the immunological competent to become ‘the survival of the fittest’? I invite readers to express their thoughts.
And when will we hear of a patient claiming that a visit to a dentist has led them to acquire the virus?
For further information visit www.talbotclinic.co.uk