key: cord-011520-qfbjars7 authors: nan title: prescribing antibiotics for urgent dental care during the pandemic date: 2020-05-22 journal: br dent j doi: 10.1038/s41415-020-1652-1 sha: doc_id: 11520 cord_uid: qfbjars7 nan we are in unprecedented times dealing with a global pandemic that is affecting the health and economics of our country and impacting personally on all of us. we recognise the difficulties for the dental profession in managing patients when there is sustained transmission of urgent dental care systems in the context of coronavirus prescribing antibiotics for urgent dental care during the pandemic key: cord-337955-4p6wbd0h authors: mark, c. title: screening figures date: 2020-09-11 journal: br dent j doi: 10.1038/s41415-020-2129-y sha: doc_id: 337955 cord_uid: 4p6wbd0h nan nhs dentistry in england in 2018 and 2019. the number of antibiotics dispensed each month by community pharmacists in england relating to nhs dental prescription forms from january 2018 to may 2020 is given in figure 1 . 3 this shows antibiotic use in may 2020 was a clear outlier compared to the previous 28 months being 18.4% higher than in may 2019 (n = 267,719 and 226,188 respectively). interestingly, antibiotic use in april 2020 was slightly higher than the previous april but still within the normal range for the period of study. this is despite the significantly poorer access to dentistry (only around 7,500 patients were seen at designated urgent dental centres [udcs] across england) compared to may when the capacity of these centres increased and saw over 27,000 patients. 4 a range of non-clinical factors are known to be associated with dentists' decision-making about antibiotics prescription for acute conditions. 2 antibiotics may have been used: • as a 'quick fix' to avoid the life-time impact of an unnecessary extraction, in anticipation that agps might soon be permissible in general dental practices • because dentists felt pressured by some patients for antibiotics, irrespective of their efficacy or appropriateness for treating toothache • because of difficulties diagnosing a patient's condition remotely prompting a 'just in case' approach through concerns of life-threatening deterioration without treatment • as some udcs were requiring patients to have tried antibiotics before accepting referral for face-to-face care, highlighting system and process impact on antibiotic prescribing. finally, the nhs may have seen an influx in patients who might otherwise receive care privately, resulting in an increase in nhs dental prescriptions as, anecdotally, not all practices were open for telephone triage during april and may 2020. examination of figures for the remainder of 2020 will reveal any enduring impact that covid interventions may have on dental antibiotic prescribing and in identifying optimisation of future dental antibiotic stewardship. v sir, pre-covid, dentists were responsible for about 10% of all antibiotic prescribing worldwide. 1 at the onset of the pandemic most dental practices were restricted to giving advice, analgesia and antibiotics (aaa). reduced access to dental care and an inability for dentists to provide dental procedures increases dental antibiotic prescribing. 2 a large increase in dental antibiotic use in england during april and may 2020 was widely anticipated and so we undertook a rapid analysis comparing antibiotic use across sir, the pre-visit triage, which practices are advised to do, will preclude any proven or probable covid-19 patients from attending a practice, leaving only the possible, undiagnosed cases as posing a risk of bringing this infection into a practice. our city council produces weekly updates of new cases, which gives a good indication of the level of infection in the population which our practice serves. when this figure is combined with the average number of patients that we have seen each week, since lockdown was eased, and the local population, this enables us to quantify the risk of us seeing an undiagnosed covid-19 patient in the practice. last week, this indicated that the average risk of seeing such a patient was one every 1,066 weeks, or one every 22.2 years. there are plenty of generalisations used in that calculation but it is certainly food for thought. povidone iodine covid-19: povidone-iodine intranasal prophylaxis in front-line healthcare personnel and inpatients (piippi). clinicaltrials.gov practical use of povidone-iodine antiseptic in the maintenance of oral health and in the prevention and treatment of common oropharyngeal infections stable compositions of uncomplexed iodine and methods of use references 1. fdi. antibiotic stewardship in dentistry -fdi policy statement: fdi world dental federation factors associated with prescribing of systemic antibacterial drugs to adult patients in urgent primary health care, especially dentistry personal communication re: dr1242 re: request for information key: cord-348403-3ahdes97 authors: watt, j. title: testing reprise date: 2020-07-24 journal: br dent j doi: 10.1038/s41415-020-1935-6 sha: doc_id: 348403 cord_uid: 3ahdes97 nan 1. gillespie c. what's the difference between asymptomatic and presymptomatic spread of covid-19? explore health 11 june 2020. available at: https:// www.health.com/condition/infectious-diseases/ coronavirus/asymptomatic-vs-presymptomatic (accessed 12 july 2020). https://doi.org/10.1038/s41415-020-1934-7 racism a global pandemic sir , the tragic death of george floyd has caused great anguish around the world but, in response, the devaluation and dehumanisation of black people has again come to the fore. this is not an american problem; structural and institutional racism is a problem everywhere around us. such racism can be overt or covert and it is important to recognise that dentistry is not immune. research has shown that dentists' decision making is affected by patient race, with black patients having a greater likelihood of having extractions than white patients. 1, 2 mistrust of dentists is demonstrated in a study reporting that black minority ethnicity (bme) participants in london believe that, because of their background, they received a poor service, were not respected, listened to or cared about by dentists compared to other non-bme patients. 3 more generally, within the nhs, ethnic minority patients at the scottish first minister's briefings, if someone is tested today and the result comes back negative tomorrow, that only proves that they were negative today. it does not prove that they will be negative tomorrow, or on whatever date they may be given an appointment under dr woodcock's proposal. regrettably, i cannot see, therefore, that his suggestion is of any help. j and clinicians face many injustices. the 2019 workforce race equality standard (wres) data report showed that a higher proportion of bme staff experienced harassment, bullying, or abuse from staff compared to white staff. 4 the bmj have a special issue on racism in medicine which is eye-opening and powerful. it reflects the experiences of doctors and patients from ethnic minority backgrounds. 5 i believe the bdj should undertake a similar enterprise to encourage more publications on race and racism. such conversations are needed within dentistry as it is not talked about as much and openly as it should be. in order to understand this subject, we must look beyond clinical dentistry and appreciate the study of social sciences, philosophy and humanities. it is engraved as a gdc standard to 'treat patients fairly, as individuals and without discrimination' . it should be embedded within us as humans from the very beginning and we must acknowledge and challenge our own personal prejudices we may have. although a recent systematic review has concluded that there is no evidence of the vertical transmission in neonates of mothers with confirmed covid-19 infection 0.0% (0/310), 2 the possibility of vertical transmission cannot be completely ruled out due to the few individual neonate cases which were reported positive a few hours after their birth. vertical infection therefore remains a possibility in the context of covid-19 thus implying a potential call-to-action for dental researchers and professionals to look for possible orofacial manifestations either in the short-or long-term, once cohorts of congenital covid-19 are reported. a i want to stress the importance of acknowledging the structural and institutional racism in dentistry specifically and in society more generally. this is an ongoing issue and we need to not only act and speak up whenever we witness injustice but to engage more in the conversation about race and racism. k. villanueva, hull, uk unconscious racial bias may affect dentists' clinical decisions on tooth restorability: a randomized clinical trial to what extent do patients' racial characteristics affect our clinical decisions? commissioning world class dentistry in kensington & chelsea and westminster: a race equality impact assessment of how the current approach to the provision of dental services is affecting bme communities racism in medicine testing reprise woodcock's letter 1 in the bdj on testing and find that his proposal has one major flaw. as prof jason leitch has said several times sir, in connection with the interesting discussion of richards et al. on coronamolars as a possible congenital disorder of the coronavirus disease (covid-19), we suggest maternal-foetal transmission (vertical transmission) to predict the coronamolars' development. 1 mulberry molars and hutchinson's teeth are characteristic dental stigmata of children born to mothers with syphilis infection during pregnancy. key: cord-006215-1ob719sh authors: sellars, shaun title: interesting times date: 2020-03-27 journal: br dent j doi: 10.1038/s41415-020-1423-z sha: doc_id: 6215 cord_uid: 1ob719sh nan as 2020 enters full swing, we find ourselves in a time of increasing uncertainty. a medium-sized corporate has recently closed its doors leaving patients, dentists and dcps with unanswered questions and mounting debts. the recruitment crisis is becoming more acute every day with many practices struggling to provide services for patients simply because there aren't enough dentists. as i write this, the government is due to announce a raft of measures to help halt the spread of covid-19, as well as mitigate the economic knock-on effect that may result. these are interesting times. as these pressures mount, it becomes more likely that each of us is going to have to make difficult decisions. decisions that will affect our jobs, businesses and the livelihoods of those that rely on our ability to provide our services. with this in mind, it would seem prudent to discuss the concept of ethical fading. american psychologists ann tenbrunsel and david messick 1 coined the term in 2004 to describe how unethical behaviour can become readily accepted in business. as a concept, it isn't limited to the corporate world and can apply directly to dental practice. ethical fading occurs when we become so focused on the other aspects of a decision that its ethical dimensions are disregarded. the moral features of the decision-making process completely disappear from view. we then justify our actions by deceiving ourselves, often in simple ways such as using euphemisms like 'creative accounting' rather than the more accurate, if less palatable, description of fraud. at the same time, we're able to claim that we have fulfilled our moral obligations. for example, if there's a shortage of face masks due to the outbreak of a new virus, should businesses be cashing in on this by inflating prices? this is clearly an oversimplification, but ethical fading can push the delicate balance of decision making down the slippery slope into dishonesty. how do we guard against this becoming the norm in times of difficulty? the obvious answer would be to emphasise the importance of ongoing ethical education in business and practice, but tenbrunsel and messick claim that this doesn't go far enough. the key driver to ethical fading, it is claimed, is the act of selfdeception and subsequent justification of actions. to combat the danger of ethical fading, then, it seems that we need to be constantly aware of the decisions we make, taking a mindfulness-like approach of maintaining a moment-by-moment awareness of our decision-making process. it is at times of stress that we most need to keep our wits about us. unfortunately, it's at these exact times that doing so becomes most difficult. we're making ethical-based decisions all the time without even realising it. paying close attention to everything we do isn't going to solve the issues, but it's a start in recognising that the problem exists. in tenbrunsel and messick's words: ' as with most embedded problems, the first step -recognising and accepting the problemis often the most difficult. ' the print copies of the bdj will now be delivered in a paper envelope, starting with volume 228 issue 6 [the current issue], published on 27 march 2020. the bdj has received a number of letters and queries in recent years regarding the polywrap that each issue was posted in, up until now. the plastic wrapping could be recycled in appropriate points such as recycling bins for plastic supermarket bags. costs for alternative postal packaging were prohibitive. james sleigh, publisher of the bdj portfolio, based at springer nature, commented: 'springer nature has been investigating alternatives to single-use polywrap for some time, but until now we weren't satisfied that there was a solution that was both environmentally more beneficial and also economically viable. however, by working closely with suppliers we are now able to move to sustainably-sourced paper envelopes, which are easily recyclable as part of normal mixed household recycling collections. 'paper envelopes are more expensive than plastic polywrap; however, by taking advantage of more efficient postal sorting options they also allow us to make some savings in distribution costs. overall, we expect the change to be cost-neutral for bda members. ' postal distribution of bdj in practice (once a month with the bdj) and the bound-in evidence-based dentistry (four times a year) is included in the change. from time to time the bdj will still be delivered in a polywrap if a complimentary product is enclosed. ethical fading: the role of self-deception in unethical behaviour key: cord-026758-drhae7vy authors: cox, m. title: incredulity and disappointment date: 2020-06-12 journal: br dent j doi: 10.1038/s41415-020-1736-y sha: doc_id: 26758 cord_uid: drhae7vy nan protection is to use a respirator hood device, however, with the proviso that not only do respirator hoods make the use of loupes/ powered light source challenging, but given the weight of the attached power pack, it can lead to postural discomfort as well as an inability to sit on stools with a back rest. as the profession begins its preparations to re-open practices, it certainly will be interesting to see how we overcome this and many other unique hurdles. k. matharu, slough, uk https://doi.org/10.1038/s41415-020-1734-0 sir, there may be some colleagues who may be slightly more worried than others about ppe in the era of covid-19: those of us with facial hair for religious/cultural reasons. fit testing of ffp3/ffp2 masks with facial hair has been largely unsuccessful with colleagues failing fit testing. where facial hair was maintained for reasons other than religious or cultural it was advised that removal would help with the seal of the ffp3/ ffp2 masks. whilst some of our medical colleagues have suggested ways in which an adequate seal can be achieved by using a thin cloth tied over a beard for example, currently the efficacy of this method has not been proven widely. increasingly, it seems that one of the plausible ways to achieve satisfactory sir, prior to the cessation of routine dentistry due to the covid-19 pandemic, the uk was trying to actively reduce the amount of waste mercury disposal. regulations were introduced in 2018 to advise on the management and use of dental amalgam as a restorative material. it was advised that amalgam should not be used in children under the age of 15 or women that are breastfeeding or pregnant, unless deemed strictly necessary by the practitioner on the grounds of specific medical needs of the patient. 1 these are unprecedented times in dentistry. waiting times and the number of patients that require to be seen has grown exponentially, carious lesions may have increased in size due to delays in follow up, cooperation from children may have decreased as desensitisation from regular dental exposure has reduced, and the nhs has come under intensive financial strain. one would ask the question, would composite still be a viable restorative material for this subgroup in these circumstances? or sir, it was with incredulity and disappointment i read the article entitled why re-invent the wheel if you've run out of road? by the chief dental officer for england (cdo). 1 the cdo references a 30-year-old book by my 'cons' professor 'dick' elderton on the merits of minimally invasive dentistry as if it were some new concept in dentistry. 2 where has dr hurley been for the past 30 years? many current dental procedures utilise some of the most cutting-edge and non-invasive techniques available today. guided implant procedures provide the most obvious example, with ct guided placement reducing surgery time, increasing long-term success, and significantly reducing levels of post-operative morbidity. there is clearly a desperate need for the reorganisation of nhs dentistry into a basic, core service, free of charge, in line with the rest of the nhs service. all other services could then be delivered via private dental practices, eliminating the often confusing and litigious mixing of 'private' and nhs dentistry. a move that would surely be welcomed by regulators and indemnifiers alike. over the past weeks we have seen many well-researched and practical standard operating procedures (sops) published by various dental associations, 3 corporate dental bodies, 4 and devolved government. 5 even with the release of the cdo's 'prompt to prepare' and 'resumption of dental services' letters published on 28 may, why are we still waiting for detailed guidance, sops and strong leadership? perhaps the cdo should recall the often-used phrase from our alma mater professor crispian scully: 'when the going gets tough, the tough get going' . the cdo rightfully recognises the leadership that many dentists have shown in england during the covid-19 pandemic. it is a shame that the profession has not witnessed the same trait in the current cdo. in a recent poll of dentists in the british association of private dentistry, 97% of its members called for the resignation of the cdo. clearly, the profession feels totally let down at this unprecedented time. the cdo's commentary merely serves to underline how out of touch the cdo is with the level of skill, expertise, knowledge, and fortitude that gdps possess to safely care for their patients and dental teams. m. cox, devizes, uk why re-invent the wheel if you've run out of road? principles in the management and treatment of dental caries bapd return to practice position paper standard operating procedures for portman dental care practices online information available at key: cord-011769-yjtwuaht authors: sellars, shaun title: back to work date: 2020-06-26 journal: br dent j doi: 10.1038/s41415-020-1788-z sha: doc_id: 11769 cord_uid: yjtwuaht nan as far back as 1785, immanuel kant advised us to treat people 'never merely as a means to an end, but always at the same time as an end. ' 1 throughout the covid-19 crisis, those in control appear to have ignored this sage advice with both dental professionals and patients increasingly used as pawns in a political game. and so, with just ten days' notice, those of us in practice were sent back to work. since then, we've been bombarded with numerous sets of sops and back to work guidance. experts and self-appointed gurus have flooded the internet with words of wisdom, some much wiser than others. i like a guideline and a protocol, but even i think that this has been a case of information overload. throughout the covid-19 crisis, the amount of, often conflicting, advice thrown towards the dental community has caused confusion, dismay and anger. some have even suggested that we should have hard and fast rules put in place by our various regulators to ensure what we are doing is correct. apart from this being beyond their collective remits, this is a bad idea. once we set a precedent for regulators to provide strict guidelines, where do we stop? currently, we're in a relatively enviable position of being allowed to practise dentistry how we see fit, within reason. allowing regulators to dictate how we're allowed to deliver those treatments leads to a much less autonomous profession. it also makes it much easier for claims of substandard practice to be levelled at any one of us who doesn't follow those guidelines. at a time when the profession feels under fire, this will only exacerbate the ill will towards those that govern us. it feels as if that ill will has increased significantly since lockdown measures were enacted. the vitriol of the profession has mainly been directed at those in charge, and specifically the cdo of england. the messages coming from our chief have not always been clear, and one would hope there would be lessons to be learned from this, especially in regards to engaging with the profession using social media. significant sectors of the profession have felt alienated throughout the covid-19 crisis, with no support from the government or their leaders. from this, new alliances have formed for the betterment of all. the profession as a whole should also be looking inwards at itself to reflect on the nature of the discourse we have participated in recently. it's worth remembering that the cdo is as much a political position as one of a leader of healthcare. the position lends itself to be as much of a pawn in the political strategy as the rest of the profession. the bitterness of much of the commentary has been unpleasant to see, let alone be on the receiving end of. i wonder if the gender of the cdo has played any part in this? now is not the time to let our shield of professionalism down. now is the time to reinforce it and become united for positive change. the british dental association (bda) has published an updated edition of its toolkit for returning to face-to-face care. it will support members and their teams to resume dental practice as safely and efficiently as possible. the toolkit will help dental teams implement the changes needed to gear up to providing appropriate treatments at appropriate times. it is for practices in england; the bda is working on versions for the devolved nations in line with developing frameworks. this latest version of the toolkit [4 june] has been updated with essential information on ppe, fit-testing, respiratory protective equipment (rpe) and the furloughed workers scheme. members can download the toolkit and related resources at: https:// www.bda.org/advice/coronavirus/pages/returning-to-work.aspx. a recently published paper in the korean journal of medical science, 'clinical significance of a high sars-cov-2 viral load in the saliva' , demonstrates the in vivo activity of chlorhexidine as a mouthwash against viruses. 1 it suggests that the in vivo activity will last for two hours and is gone by four (and not repeatable when the mouthwash is tried again at day six) but also confirms the very high levels of sars-cov-2 in saliva and in the nose. the general conclusion from studies of antiviral activity of mouthwashes in vitro suggests that chlorhexidine is not as effective as povidone iodine, but this study suggests that it does have antiviral activity and could be considered as a backup. groundwork of the metaphysics of morals (1785) clinical significance of a high sars-cov-2 viral load in the saliva key: cord-011771-vganve2b authors: gallichan, n.; heggie, c.; lee, s.; messahel, s.; albadri, s. title: paediatric emergencies date: 2020-06-26 journal: br dent j doi: 10.1038/s41415-020-1796-z sha: doc_id: 11771 cord_uid: vganve2b nan sir, in mid-march when the lockdown began i was contacted by the nhs and notified that due to my diagnosis of crohn's disease i had been placed in the highly vulnerable category and thus was advised to shield for 12 weeks. whilst the cdo issued guidance on 28 may 2020 that dentists will return to work on the 8 june in england there has been no guidance on how this applies to those, such as myself, who are in the shielded category. the initial 12-week period of shielding is set to finish at the end of june, however, there are now suggestions that this will be extended further. despite this, there has been no clarification as to whether this applies to all shielded individuals or whether this should be decided on a case by case basis on the advice of one's doctor (my own medical team have informed me they are unsure of how the shielding rules apply to dentists and have not received any further guidance on this matter to date). as a general dental practitioner, i am anxious to get back to work and to provide a much-needed service to my patients and i am sure there are many colleagues who find themselves in the shielded category that share this sentiment. it would be much appreciated, therefore, if the cdo, nhs england or the bda could consider cases of dentists, and other healthcare professionals, such as myself and issue further guidance as to when it is safe to return to practice. k. oberai, twickenham, uk https://doi.org/10.1038/s41415-020-1795-0 children undertaking exercise and activities at home with school closures, more accidental injuries may occur. it is also important to consider the possibility of tdis related to non-accidental injury during lockdown, with children living in violent or dysfunctional families having limited access to safe spaces, friends, teachers and support outside the home in this period, leading to an increase in domestic violence and abuse. 2 on presentation, it is important to take a thorough history and examination, identifying any discrepancies which may raise suspicion. 3, 4 the bspd have published excellent guidelines to aid us with the management and follow up of tdis during the covid-19 pandemic. 5 secondly, we found that the number of admitted patients decreased, suggesting that conditions of lower severity were presenting to the ped. this may also be attributable to a lack of alternatively available dental services. finally, as a result of the pandemic, thousands of children nationally have experienced cancellation of dental general anaesthetics (ga), with cases being prioritised as per national guidelines. 6 subsequently, thousands of children have been left in pain, taking regular analgesics and sometimes requiring multiple courses of antibiotics. indeed, the number of children receiving repeat courses of antibiotics from the ped increased in the covid affected period. with gdps reopening and reaching a 'new normal' , the emergency management of tdis and children in pain should be considered a priority in paediatric primary care triage to reduce the subsequent burden on tertiary services, which carries increased expense to the nhs. n. gallichan, c. heggie, s. lee, s. messahel, s. albadri, liverpool, uk sir, whilst there has been a significant decrease in attendance to emergency departments during the covid-19 pandemic, 1 the paediatric emergency department (ped) at alder hey children's hospital has observed little change in the number of dental attendances. we compared the characteristics of attendances in march, april 2020 to the same months in 2019 with three key findings to consider in the months ahead, as we resume dental services. firstly, the number of children attending the ped with traumatic dental injuries (tdis) increased in the covid-19 affected period. this may be due to decreased availability of primary care dental services in the region. additionally, with more sir, eye contact and verbal communication with a child play a key role in nonpharmacological behaviour management. during this pandemic, when i visited a patient for dental urgency, i addressed the child in a conventional ppe kit abiding by the disinfection and safety protocols. the child was completely surprised and frightened and was hesitant in allowing examination. so i spent a couple of hours tweaking the conventional ppe kit with a child-friendly touch that included incorporation of famous cartoon characters and emoticons to make the child happy (fig. 1) . i performed this in a sterile environment following the sanitisation protocols. next time i entered the treatment room in the customised ppe kit there was an overwhelming response from the child who underwent the treatment procedure with no sign of anxiety or fear. in addition, the   fig. 1 customised ppe for paediatric dentistry british dental journal | volume 228 no. 12 | june 26 2020 901 upfront a&e attendances and emergency admissions joint leaders' statement. violence against children: a hidden crisis of the covid-19 pandemic 2020 injuries to the head, face, mouth and neck in physically abused children in a community setting child abuse and dentistry: orofacial trauma and its recognition by dentists british society of paediatric dentistry. trauma guidelines for primary/permanent dentition recommendations for paediatric dentistry during covid-19 pandemic key: cord-255635-0pr9oae6 authors: riad, a.; yilmaz, g.; boccuzzi, m. title: molecular iodine date: 2020-09-11 journal: br dent j doi: 10.1038/s41415-020-2127-0 sha: doc_id: 255635 cord_uid: 0pr9oae6 nan sir, i write with my thoughts on three recent items published in the bdj. 1, 2, 3 in relation to fit testing for ffp3 respirators, 1 an additional consideration is that the occupational safety and health administration have advised that prescription glasses, or where required safety goggles, must be worn during the fit test. 4 the author cited reasons for undergoing a fit test, one of which was facial change since the previous test. it would be interesting to note that major dental work such as new dentures would fall under this category. secondly, in relation to thermal screening 2 the cdc in its guidelines for dental settings recommends that a patient should not be deferred treatment for the sole reason of being febrile ie a clinical correlation of the fever must be made. 5 the same guidelines recommend that the definition of fever be updated to either a measured reading of ≥100.0°f or subjective fever. if a patient is found to be febrile with a strongly associated diagnosis of dental origin such as the presence of intra-oral swelling and pulpal/ periapical dental pain with the absence of symptoms suggestive of covid-19, dental care may be provided following routine protocol. finally, in relation to orthodontic treatment 3 this author mentions the use of self-etch primers (sep) to avoid an agp, however the technique of applying sep involves gentle air drying according to some manufacturers, making it a potential agp. there is also a mention of utilising light cured resin modified gic, but this material does not require a dry field and in fact, the surface of the enamel should be moist during bonding to ensure success. 6 the author suggests hand trimming of excess composite/flash with a scalpel. an alternative to this would be to utilise either: band removing pliers (posterior teeth), hand scalers/mitchell's trimmers (incisors) or adhesive removing pliers. 6 minimal remnants of residual material on the enamel surface can be lost with time as a result of toothbrushing. 6 v. sahni, new delhi, india https://doi.org/10.1038/s41415-020-2117-2 workers. 2 the mechanism of action of pvp-i relies primarily on the free iodine component, which is bound to a large polyvinylpyrrolidone molecule (pvp) acting as a carrier to deliver i 2 to target cells. however, the viricidal activity of pvp-i is highly associated with its i 2 content: the commonly used 10% pvp-i can only deliver 1-3 ppm of i 2 in a compound of more than 31,600 ppm of total iodine atoms. the high percentage of bounded 'non-active' iodine contributes to all the undesirable toxicological and staining properties of pvp-i. 3 a new generation of iodine-based antiseptics 'super iodine' was initiated recently to overcome the compositional side effects of pvp-i. therefore, iotech international (boca raton, fl) produced a patented aqueous solution of i 2 that contains over 100 times more i 2 than pvp-i and comes in various forms ready for prophylactic use including mouthwash, nasal spray, and hand cleanser. 4 moreover, the non-bioactive iodine content was reduced from 31,600 ppm in pvp-i to several hundred in the new formula thus accelerating its effect, increasing its shelf-life, and minimising its potential irritancy and mucosal staining. in comparison to several antiseptic mouthwashes, the new i 2 formulas showed higher viricidal efficacy against coronaviruses and took as short as 30 seconds to inactivate alpha coronaviruses (229e) completely. 4 the same was observed in rhinovirus which was totally inactivated above the cytotoxicity level after exposure to the new i 2 formula for 30 seconds. 4 to the best of our knowledge, there is an ongoing randomised control trial at st. joseph's hospital university (paterson, nj) to evaluate the efficacy of i 2 mouthwashes and nasal sprays in protecting frontline healthcare workers by reducing their susceptibility of getting infected by sars-cov-2. therefore, sir, we have read with great interest the correspondence of challacombe et al. on the antiseptic efficacy of povidone-iodine (pvp-i) against sars-cov-2; we aim to demonstrate the potential prophylactic capacity of the new generation of uncomplexed molecular iodine (i 2 ) mouthwashes. 1 pvp-i has been a gold standard antiseptic for decades with proven efficacy against the previously identified beta coronaviruses; it was one of the first candidates for the emergency trials attempting to establish an additional layer of protection for frontline healthcare comment letters to the editor send your letters to the editor, british dental journal, 64 wimpole street, london, w1g 8ys. email bdj@bda.org. priority will be given to letters less than 500 words long. authors must sign the letter, which may be edited for reasons of space.  we suggest more controlled trials to be initiated using i 2 products to benefit from their potential superiority over conventional pvp-i mouthwashes. a. riad, brno, czech republic; g. yilmaz, istanbul, turkey; m. boccuzzi, pisa, italy nhs dentistry in england in 2018 and 2019. the number of antibiotics dispensed each month by community pharmacists in england relating to nhs dental prescription forms from january 2018 to may 2020 is given in figure 1 . 3 this shows antibiotic use in may 2020 was a clear outlier compared to the previous 28 months being 18.4% higher than in may 2019 (n = 267,719 and 226,188 respectively). interestingly, antibiotic use in april 2020 was slightly higher than the previous april but still within the normal range for the period of study. this is despite the significantly poorer access to dentistry (only around 7,500 patients were seen at designated urgent dental centres [udcs] across england) compared to may when the capacity of these centres increased and saw over 27,000 patients. 4 a range of non-clinical factors are known to be associated with dentists' decision-making about antibiotics prescription for acute conditions. 2 antibiotics may have been used: • as a 'quick fix' to avoid the life-time impact of an unnecessary extraction, in anticipation that agps might soon be permissible in general dental practices • because dentists felt pressured by some patients for antibiotics, irrespective of their efficacy or appropriateness for treating toothache • because of difficulties diagnosing a patient's condition remotely prompting a 'just in case' approach through concerns of life-threatening deterioration without treatment • as some udcs were requiring patients to have tried antibiotics before accepting referral for face-to-face care, highlighting system and process impact on antibiotic prescribing. finally, the nhs may have seen an influx in patients who might otherwise receive care privately, resulting in an increase in nhs dental prescriptions as, anecdotally, not all practices were open for telephone triage during april and may 2020. examination of figures for the remainder of 2020 will reveal any enduring impact that covid interventions may have on dental antibiotic prescribing and in identifying optimisation of future dental antibiotic stewardship. v sir, pre-covid, dentists were responsible for about 10% of all antibiotic prescribing worldwide. 1 at the onset of the pandemic most dental practices were restricted to giving advice, analgesia and antibiotics (aaa). reduced access to dental care and an inability for dentists to provide dental procedures increases dental antibiotic prescribing. 2 a large increase in dental antibiotic use in england during april and may 2020 was widely anticipated and so we undertook a rapid analysis comparing antibiotic use across sir, the pre-visit triage, which practices are advised to do, will preclude any proven or probable covid-19 patients from attending a practice, leaving only the possible, undiagnosed cases as posing a risk of bringing this infection into a practice. our city council produces weekly updates of new cases, which gives a good indication of the level of infection in the population which our practice serves. when this figure is combined with the average number of patients that we have seen each week, since lockdown was eased, and the local population, this enables us to quantify the risk of us seeing an undiagnosed covid-19 patient in the practice. last week, this indicated that the average risk of seeing such a patient was one every 1,066 weeks, or one every 22.2 years. there are plenty of generalisations used in that calculation but it is certainly food for thought. ffp3 respirator face fit testing -what is it all about? thermal screening agps and orthodontics transcript for the osha training video entitled respirator fit testing the agp question: implications for orthodontics povidone iodine covid-19: povidone-iodine intranasal prophylaxis in front-line healthcare personnel and inpatients (piippi). clinicaltrials.gov practical use of povidone-iodine antiseptic in the maintenance of oral health and in the prevention and treatment of common oropharyngeal infections stable compositions of uncomplexed iodine and methods of use references 1. fdi. antibiotic stewardship in dentistry -fdi policy statement: fdi world dental federation factors associated with prescribing of systemic antibacterial drugs to adult patients in urgent primary health care, especially dentistry personal communication re: dr1242 re: request for information key: cord-014333-54ow0ckn authors: ireland, robert title: expert view: robert ireland date: 2020-11-13 journal: br dent j doi: 10.1038/s41415-020-2384-y sha: doc_id: 14333 cord_uid: 54ow0ckn nan the covid-19 pandemic has created a number of unique challenges. notably on 25 march 2020 we were advised to halt all non-urgent care, remotely triage our patients and provide advice using the 3as. patients would then be referred to urgent care centres if required. practices developed triaging services in numerous ways, however, the practice in this study already had a longstanding out-of-hours nurse-led triage service in place which put them in an ideal position. in medical practice, nurseled triage has been shown to reduce general practitioner contacts by 16%. 1 could nurseled triage also be as effective in general dental practice? this study covered a triage service in one private practice from 25 march 2020 to 12 june 2020. calls would be answered by the reception staff and then passed onto the triaging nurse. if support was required, it would be escalated to the dentist on call or the clinical lead for complex situations. follow up contacts were arranged if required. a separate system was in place for orthodontic emergencies. seventy patients were triaged during this period. the most common reasons for contacting the practice were pain, followed by loose extra-coronal restorations and then fractured teeth, crowns or bridges. of the patients, 68.5% were managed successfully without input from the dentist. whereas 25% of the patients were passed onto a dentist and 5.7% to the clinical lead. antimicrobials were only needed for five out of the 70 patients and no patients required referral to an urgent care centre. sixteen patients called multiple times, and ten of these were managed exclusively by the triaging nurse. twenty-seven of the patients triaged declined an appointment when offered, for multiple reasons, including the problem resolving, wanting to wait or having shielding family members. the study shows most patients were managed successfully by the triaging nurse on the first call. there were also no concerns from the dentists about the way patients were managed. the study has shown how a whole-team approach to triaging can work advice' is within the scope of practice of the dental nurse but diagnosing is not. covid-19 has forced the reconsideration of the provision of emergency dental care and the triage pro forma forms an important part of the filtering process, of which there are some comprehensive examples of flowcharts available applicable to the covid-19 pandemic 2,3 which in this study helped to reduce further appointments by 39%. it is of concern that some patients were unable to contact their own dentist since the absence of an efficient out-of-hours on-call service is likely to elevate patient stress and potentially negatively impact on a patient's pain threshold, particularly at the time of a pandemic when access to emergency dental care might be restricted. this limited study opens up the opportunity to consider further research such as exploring the level of patient satisfaction with online triage, the costeffectiveness of utilising dental nurses and the satisfaction of dental nurses broadening their scope of activity within the dental team and their enthusiasm for doing so. dental nurse triage of patients with dental emergencies conference: iadr general session and exhibition management of acute dental problems during the covid19 pandemic triaging of non-scheduled appointments in general dental practice: a clinical audit although this is a limited retrospective study, and therefore the results should be interpreted with caution, this article provides an interesting, relevant and positive example of how the resources of the dental team can be more fully utilised and how the flexibility of a well-trained dental team can adapt efficiently and effectively to a sudden and unexpected change in the provision of emergency dental care.this study demonstrates how the triage workload can be redistributed (68% of patients being managed without dentist input) which supports earlier research demonstrating 85% agreement between the triage dental nurse and the dentist (of the 15% where there was disagreement between the dentist and the triage dental nurse, in half the cases the nurse had given a higher triage category than the dentist and in the other half the dentist had given a higher triage category than the nurse). 1 dental nurses certainly have the skill set to undertake the role of patient emergency triage subject to having undertaken appropriate training and calibration, bearing in mind that providing 'appropriate patient evaluation of a dental nurse-led triage system in a private dental practice during the covid-19 pandemic. br dent j 2020; 229: https://doi.org/10.1038/s41415-020-2177-3. key: cord-014337-nnuvrb6o authors: byrne, s. title: scientific rigour date: 2020-11-13 journal: br dent j doi: 10.1038/s41415-020-2362-4 sha: doc_id: 14337 cord_uid: nnuvrb6o nan for dental education and training, while measures are in place to control the spread of covid-19. version 2. 1 september 2020. available at: https://www. gdc-uk.org/news-blogs/news/detail/2020/09/01/ joint-statement-on-arrangements-for-dental-educationand-training-while-measures-are-in-place-to-control-thespread-of-covid-19-(version-2-dated-1-september-2020) (accessed november 2020). https://doi.org/10.1038/s41415-020-2360-6 oral research sir, i read with interest the paper by sampson et al. 1 regarding a possible link between the severity of sars-cov-2 infections and oral hygiene. their call for excellent oral hygiene as a strategy to potentially aid the prevention of bacterial superinfections in patients with sars-cov-2 infections is not in question here. however, i draw attention to the interpretation of research findings by the authors, and would caution against reporting associations between covid-19 symptoms and oral bacteria without the support of adequate data. postgraduate periodontal training at the university of texas health science center at houston (houston, tx, usa) in response to substantial interruptions in didactic and clinical training. first, we identified our immediate goals: 1. to evaluate the existing curricula and reorganise them by adopting the commission on dental accreditation (coda) compliance protocols on the interruption of education and distance education to allow for a continuation of the pgrs' hands-on and didactic learning 2. to calibrate all full-and part-time periodontal faculty 3. to transition the residents through their respective clinical curricula 4. to provide feedback on the residents' surgical skills. once these goals were met, we aimed to implement the following sessions to allow for the transition of pgrs through the updated curricula: 1. case-based classroom videos from the american academy of periodontology (aap) and webinars allowed residents to enhance their didactic knowledge on clinical techniques 2. clinical case presentations through online sessions allowed continued pgrs' feedback to enhance their presentation and treatment planning skills as well as surgical techniques 3. sessions with invited speakers allowed pgrs to learn clinical management with the experts in the field and receive constructive feedback of greatest concern, sampson et al. 1 report that sequencing data indicate high reads for prevotella, staphylococcus and fusobacterium in patients severely infected with sars-cov-2. the supporting data come from a letter by chakraborty. 2 it is unclear in which publication this letter appears or whether it has been through a peer review process. in the letter, metagenomic sequencing data from five patients are presented. 2 no methods, including no source for the samples is given. this, along with a lack of data from healthy subjects, makes it impossible to draw any conclusions about the number of sequencing reads relating to these genera and any association with sars-cov-2 infection. these data can therefore not be used to associate 4. collaborative seminars in surgical, prosthetic and restorative dentistry with the department of periodontics at the university of illinois at chicago allowed pgrs to get exposed to world-class periodontists and dental implantologists and ask one-on-one questions 5. suturing training modules allowed pgrs to practise suturing at home and learn indications of various techniques 6. virtual sedation cases were utilised to accomplish pgrs' sedation competencies 7. mock periodontal oral board sessions allowed pgrs to prepare for the aap specialty board examination and fulfil temporary coda requirements in certain competencies 8. as laboratory research activities were suspended, pgrs were asked to work towards their master's thesis writing and analysis of the existing data. despite facing changes in a teaching format, especially in clinical training, our approaches, including the use of online portals and modules, maintained and enhanced pgrs' hands-on and didactic experiences. we expect to implement these new teaching approaches in future curricula. the authors also refer to nagaoka et al. 5 as evidence for a relationship between prevotella intermedia and severe pneumonia. this is an in vivo study examining the effect of a bacterial supernatant on experimentally induced pneumonia in mice, and not an observed relationship in human subjects. a global health crisis such as we are experiencing places huge pressure on health professionals and the research community in the rapid search for knowledge. whilst sir, the pandemic has forced dental institutions to change approaches to teaching undergraduate dental students and postgraduate residents (pgr). with great interest we have read recent letters and publications in the bdj 1,2 and elsewhere that outline the approaches our european colleagues have taken. in this letter, we would like to describe our approaches to modify   improving oral hygiene is unlikely to be detrimental, it has never been more important to uphold scientific rigour in the interpretation and reporting of research findings to help build our collective understanding of the aetiology and prevention of disease. s recommendation. this will make handovers concise and easy to follow • make sure to rest properly in your spare time -the job can be demanding so this is vital to stay alert. and lastly, enjoy this time! you will see extremely interesting cases through to the weird and wonderful; you have an amazing opportunity to learn new things in a supported environment so take advantage of it! a. kazmi, liverpool, uk https://doi.org/10.1038/s41415-020-2363-3 sir, i write further to the letter of kalsi et al. 1 in which they described that the product alvogyl (septodont, cedex, france) used in the management of acute fibrinolytic alveolar osteitis had been superseded by a chemically different product alveogyl (septodont) with potentially significant clinical ramifications. these colleagues make a very valuable and important point in that the formulations of not only pharmaceuticals but also dental materials and biomaterials may be changed by manufacturers surreptitiously. this may be necessary due to product development, regulatory demands and ongoing product safety. whilst this is both laudable and proper, the clinician should be mindful of potential changes in product formulation as this may have a significant bearing on how the product is mixed and/or handled clinically. it therefore follows that the failure of the dental team to fastidiously use the material as intended may result in inferior clinical performance. one way of ensuring best practice would be that the directions for use of each new batch of product are read carefully and then stored in a centrally placed file in the clinic, easily accessible to all members of the dental team. a ring binder folder containing punched pockets is ideal and the responsibility of keeping the file contemporaneous should lie with the member of staff responsible for stock management. 2 furthermore, dissemination of any change in handling protocol etc should also be communicated to all appropriate clinical staff. such a measure will ensure that all products intended for clinical use are used correctly to ensure the best outcome for the patient. s. j. bonsor, aberdeen, uk https://doi.org/10.1038/s41415-020-2365-1 emergency dentistry sir, having completed a year as an omfs dct in a major trauma unit, i thought it would be useful for fellow colleagues to have some know-how of how to survive an on call: • if in doubt, ask: senior colleagues will know you haven't done the job before. they have experience of training dcts and will be more than happy to assist you • get to know the paperwork. as laborious as it may be, paperwork is extremely important, and the more you are aware of what needs to be filled in, the smoother the process will be • prioritise your jobs. you will have calls coming from multiple different places at the same time, so you need to know which jobs need to be finished urgently, and which jobs can be completed later • keep a logbook -preferably electronic but if it is in paper form, make sure there is no patient information which will make them identifiable, and make sure to get it verified by your consultant • practise suturing at home. i know it sounds simple, but practising a little can go a long way! you will come across as more confident in front of the patient and will feel less fazed • watch videos on how to cannulate -once again, it will be unlikely you will have sir, thank you for publishing martin kelleher's article (bdj 2020; 229: 225-229). martin has long been highly respected as an excellent teacher and communicator, and a voice of reason in our profession. the first part is a truly appalling account of just one problem at the gdc. the second is an excellent reminder that we must not let lawyers overrule common sense in the way we practise. the profession needs a regulator (note not plural) with an understanding of what comprises good dental practice. in the meantime we look to the bda and its esteemed journal to continue the fight on behalf of our profession. p. s. nayler, brighton, uk https://doi.org/10.1038/s41415-020-2364-2 sir, there is an increasing number of dentists who have started to provide specialist skin care. may i emphasise, i do not mean facial aesthetics courses (botulinum toxin and fillers). this is after they have gone to a alternative teaching aids vr systems in dental education alvogyl or alveogyl a clinical guide to applied dental materials key: cord-271612-dmgb3gta authors: rollings, laura title: ffp3 respirator face fit testing what is it all about? date: 2020-07-24 journal: br dent j doi: 10.1038/s41415-020-1850-x sha: doc_id: 271612 cord_uid: dmgb3gta coronavirus and the resultant pandemic have changed how dentists work. dental professionals require a fit test to wear a certain type of personal protective equipment (ppe) the filtering facepiece class 3 (ffp3) mask. we explain two types of fit tests: quantitative and qualitative, with step-by-step images demonstrating the latter. the four reasons for having a face fit test will be explained. this article will introduce and explain the fit check, which should be performed every time a ffp3 mask is worn. the new coronavirus was first discovered in wuhan in december 2019. 1 its resultant disease was officially named covid-19 (ie coronavirus disease 2019) by the world health organisation in february 2020. 2 as a result of the current pandemic, personal protective equipment (ppe) is undoubtedly at the forefront of many dental professionals' thoughts. ppe requirements are detailed in the nhs's standard operating procedure: transition to recovery publication, 3 which should be adapted locally. countless professionals have undergone or are awaiting a fit test for a filtering facepiece class 3 (ffp3) respirator. 4 like many, this will be a new concept. there are two tests available: quantitative and qualitative. 5 a ffp3 respirator, 4 also referred to as a ffp3 mask, 6 is a type of ppe. there are different types, sizes and models of ffp3 masks. 6 ffp3 masks include the 3m 8833 7 (fig. 1 ) and 3m 1873v 8 (fig. 2) ; there are similarities and differences between them. at the anterior aspect of the mask, they both have a central valve; this design allows heat to escape and reduces eyewear fogging. 7, 8 as for comparisons, the 3m 8833 has a cushioned liner inside a sturdy shell shape with an external nose clip, which should be moulded to the clinician's nose, 7 whereas the 3m 1873v mask has a smooth lining found within three panels which are folded out to be worn; the panel covering the chin is adjustable 8 and there is a mouldable nose fitting which is located internally. 8 as dental professionals, we perform aerosol generating procedures (agps), such as using the high-speed handpiece; 4 these produce airborne particles -ffp3 masks help to avoid their inhalation. 4 the health and safety executive (hse) has indicated that the ffp3 masks have ≥99% (95 l/ min) filter efficiency and have a total inward leakage of ≤2%; this includes a facial seal leak. 5 to aid ppe selection, a local risk assessment is required. 9 prior to wearing a ffp3 mask, you need to have passed the face fit test -if there is an inadequate seal, your protection can be undermined. 6 the two types of respiratory protective equipment (rpe) fit tests are: 1. qualitative: when wearing a mask and hood, a solution is sprayed; the candidate should not be able to taste the solution (sweet or bitter). 5 this test can be used with half masks, not fullface versions 10 2. quantitative: a comparison between the particle proportions in and out of the mask. 5 this test can be used with both half-and fullface varieties of the masks. 10 there are different reasons for having a face fit test, including needing a repeat fit test (fig. 3 ). 6 the test is carried out by one person. you should notice them adhere to social distancing, positioned away from you when delivering the instructions and when demonstrating how to put a mask on. 6 each person tends to have a 30-minute slot allocated to their test. prior to the fit test, a taste sensitivity screening is performed. you should be nil by mouth (including chewing gum) and should not smoke for at least 15 minutes before your taste sensitivity screening/fit test. 11 a hood is placed over your head (fig. 4 ) and you should have you mouth open slightly. the operator then squeezes the bulb of the nebuliser, 11 producing an aerosol in the hood (fig. 5) ; you must indicate if you can detect its taste 11 (some are sweet, some bitter). if you are sensitive to the taste, you can then proceed to the fit test; if not, a different fit test is needed. the hood is removed and you should drink water to help eliminate the aerosol taste before your fit test. 11 the fit test begins with a demonstration of how to put on a ffp3 mask by the tester. the candidate then puts their own mask on and moulds it to their face. it is useful to either use a mirror 11 or have a colleague visually check you have the mask on correctly (for example, checking hair is not trapped in the seal of their mask). as part of the fit test, a fit check is performed. exhale and place your hand around, but not touching, the mask; you should not feel air escaping (for example, from under your chin). you may, however, feel air expel through the mask valve. the hood is then placed over your head again. the aerosol is once again sprayed, this time while you perform various tasks (each for 60 seconds). 11 you should indicate to the tester if you can taste the aerosol at any point in the fit test. the tasks are performed in this order: 1. breathe normally (as you did in the taste sensitivity screening) 2. breathe deeply 3. move your head side to side (fig. 6) 4. move your head up and down (fig. 7) 5. read aloud -a text may be provided to you 6. jogging/position yourself as you would if you were performing a dental procedure 7. repeat step one. this is likely to be the reason many dental professionals are being tested currently; a new concept to most of us. you should not wear the mask without knowing you have an adequate seal. if the mask does not fit you well enough (failed fit test}, you may be asked to return for a test with a different mask (ie a variant on type, size or model). the mask you were fitted with may no longer be available, therefore you need to be re-fitted for the mask now available to you. if tested within one trust, but you work for an additional trust, check -they may have different masks. this can include facial surgery or weight change. if you do not taste the aerosol during your test, you have passed the test and the mask is deemed to provide an adequate fit for you. if you do taste the aerosol, you have failed the test and the mask is deemed an inadequate fit for you; 11 you may be retested with a different type, size or model of a ffp3 mask. 6 as a fit test candidate, it would be beneficial to record the date and result (that is, pass or fail) of your fit test, 10 in addition to taking a photograph of the mask you were tested with to act as an aide memoire. in contrast, you may be adopting the role as a fit tester. for this, you must be competent 10 and have undergone training, 12 such as that offered by the accredited provider fit2fit 10,13 recognised by hse. for each candidate you fit test, documentation should be made, including their name, the test result, the type of mask tested with and the method used (qualitative or quantitative). 10 indemnity providers are providing different cover for those performing fit testing; 12,14 check with your own indemnity provider to ascertain which cover you have for providing fit tests. certain facial hair forms cause some masks to be incapable of obtaining an adequate seal to your face, which therefore affects your protection against the virus. 15 the centres for disease control and prevention (cdc) have indicated which styles would not be compatible with the respirator: stubble, full beard and extended goatee. those suggested as acceptable are a: soul patch, side whiskers and walrus moustache. 16 please note these lists are not exhaustive. there are reasons some people cannot remove their beard (that is, on religious grounds); the hse has indicated that there are alternative rpe. 15 covid-19 is changing the way in which dental professionals work. a ffp3 mask can be an important and essential part of our ppe. you should perform and pass a fit test before wearing a ffp3 mask. moreover, it is important to know that every time you wear a ffp3 mask, you should perform a fit check; this should not substitute a fit test. 5 world health organisation the centres for disease control and prevention. frequently asked questions standard operating procedure: transition to recovery -a phased transition for dental practices towards the resumption of the full range of dental provision available at https:// www.gov.uk/government/publications/wuhan-novelcoronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe rapid evidence review fit testing face masks to avoid transmission: coronavirus (covid19) 3m. 3m™ disposable respirator, ffp3, valved, 8833 ~/3m-aura-disposable-healthcare-respirator-ffp3-valved-1873v-/?n=5002385+3292 799385&preselect=3293786499&rt=rud research: review of personal protective equipment provided in health care settings to manage risk during the coronavirus outbreak guidance on respiratory protective equipment (rpe) fit testing bitrex: qualitative fit test instructions covid-19 resources: supporting you when you need it bsif. fit2fit accreditation. available online at fit testing of masks -dental protection position statement fit testing basics centres for disease control and prevention. to beard or not to beard? that's a good question! 2017 the author would like to acknowledge dr saba mirza (dental officer, worcestershire community dental service) for the photographs used in this publication. key: cord-013311-r10f5yb0 authors: javed, m.; bhatti, y. title: frugal solutions date: 2020-10-23 journal: br dent j doi: 10.1038/s41415-020-2294-z sha: doc_id: 13311 cord_uid: r10f5yb0 nan sir, as a past president of the bda i am dismayed and bemused to read frequent reports in national newspapers decrying the number of children awaiting many months for tooth extractions in hospitals. indeed, the daily telegraph claims that this is the most frequent referral cause for children to hospital, numbering equating to 177 cases per day nationally at an estimated cost of £41 million. a further report of this problem appears in the recent bdj (potential surge in post-covid child tooth extractions; bdj 2020; 229: 278). is this because dentists, both in practices and community dental services, are either unwilling or unable to perform this treatment? furthermore, it seems that frequent courses of antibiotics are prescribed to keep infection from carious teeth at bay pending hospital extraction. as we are all too aware, this repeat prescribing is undesirable, building up unnecessary resistances. i presume dental schools still educate undergraduates in the expert technique of extractions, therefore one must conclude that the problem is due to an unwillingness of clinicians in primary care to undertake these treatments. we must remember that for every child suffering from painful teeth, there are parents having to cope with stressful situations. many years ago, i was a member of the then termed 'poswillo' working party, reporting to the department of health on the safety of administering general anaesthetics (ga) in practices, but additionally our role included reviewing other means of anaesthesia. whilst not advocating a return to providing gas in outpatient clinics, in a primary care setting it is perfectly possible and permissible to extract offending teeth using either sedation or local anaesthesia or a combination of both. as healthcare professionals, dentists have a duty to relieve pain and to prevent the risk of complications arising from long-term infections rather than referring patients to a seemingly endless waiting list, especially during these difficult covid-19 times, which is exacerbating this dire state of affairs. j. stuart robson, york, uk https://doi.org/10.1038/s41415-020-2282-3 used a purpose built protection box during aerosol generating procedures (https://www. facebook.com/dentistsatwork). these solutions may not be perfect but they can provide necessary protection in the best and quickest way possible in the face of exponential spread of the pandemic and economic limitations. m. javed, qassim, saudi arabia, y. bhatti, london, uk sir, in the current pandemic, the lack of equitable oral healthcare facilities, shortfall of dental healthcare providers, shortages of equipment/materials, and inadequate management of existing services is well known in developing countries. 1 it may not be possible for such countries to upgrade the dental surgeries in their tertiary care facilities to the suggested level of ventilation, filtration, and negative pressure, due to financial limitations. the alternative solution for resource constrained environments is to explore frugal innovation approaches to make the most of existing assets and skills. 2, 3 for instance, for creating a temporary negative pressure in dental surgeries strong exhaust fans have been connected to the simple duct system to deliver the air from the surgery at the minimum three metres above the roof. 4 to prevent the transmission of infection through aerosol in the dental setting the 'protection box' is an innovative and economical solution for performing aerosol generating procedures. 5 the protection box has excellent visibility and can be reused after disinfection. recently, in pakistan a dental surgeon has designed and sir, i would like to thank all my colleagues who have worked so diligently to up-skill and kindly help guide others through the current covid-19 pandemic. until six months ago, like many colleagues, i had little knowledge of this new respiratory virus and its impact on the dental profession. thanks to this new novel virus, we now have a growing number of colleagues within dentistry who understand much more about respiratory viruses than i ever seem to remember learning at dental school or during my postgraduate studies. if we add to this the long list of acronyms with sops, agps, non-agps, ffps, written and re-written sops, the latest technology to help oral health care systems in developing and developed countries fast and frugal innovations in response to the covid19 pandemic frugal and reverse innovation in surgery frugal solutions for the operating room during the covid-19 pandemic patients' case scenario as well as approaches and strategies adopted to manage covid-19 pandemic at aligarh muslim university letters to the editor send your letters to the editor, british dental journal, 64 wimpole street, london, w1g 8ys. email bdj@bda.org. priority will be given to letters less than 500 words long. authors must sign the letter, which may be edited for reasons of space. key: cord-011512-gw2sk90q authors: houlston, e. title: a simple pleasure date: 2020-05-22 journal: br dent j doi: 10.1038/s41415-020-1683-7 sha: doc_id: 11512 cord_uid: gw2sk90q nan responses from various regions across the uk: 41.7% had already been redeployed into secondary care, with the remainder either waiting to hear about their new placement or had not redeployed. by rating individual factors on a 5-point likert scale, we were able to determine what influenced their willingness to be redeployed as their decision is a voluntary one. perceived lack of provision of adequate ppe, risk of exposure and transmission of covid-19 to family and friends, and provision of adequate training prior to taking on new roles were ranked highly as deterrents to redeployment. gaining new skills during redeployment and wanting to work in a larger team ranked highly as positive factors. interestingly, factors such as working extra or unsociable hours, working in a new location or in a hospital were not ranked as major preventative factors. in terms of assessing skillsets that dfts held at the time of redeployment in relation to working in icu, on average responders had low confidence levels regarding familiarity with icu lines, phlebotomy, and cannulation. as dcts we can reassure our junior colleagues that these skills can be learnt with support and will be useful if they are considering further postgraduate training. these factors provide insight into the driving forces to recruit young clinicians into an unfamiliar role. they may be useful for key decision makers if we were to have a second peak or another pandemic. sir, the british orthodontic society (bos) and the oral health foundation have recently collaboratively launched a muchawaited campaign, safe brace campaign, alerting the public to the dangers of direct to consumer orthodontics, also known as 'diy braces' (www.safebrace.org). both organisations provide patients with expert and evidence-based information that relates to their oral, orthodontic and overall health. the campaign was launched after the recent statement released by the general dental council recommending that for all dental interventions patients should have a face-to-face consultation with a trained clinician at the beginning of treatment. this is of paramount importance as patients need to make informed decisions about their treatment, and the only way to do so, is for the patients to see a trained clinician in person to discuss the treatment (and indeed alternatives) in detail (including risks and complications) so that they are fully informed of what to expect from the outset. jonathan sandler, bos president, said: 'in my professional opinion, if you embark on any orthodontic treatment without a suitably trained clinician taking the time to examine you and make appropriate recommendations, you could be in danger of having serious conditions missed, as well as inappropriate and dangerous treatment carried out. what other transforming dental or medical treatment would you undergo, without an in-person evaluation or supervision by a medical professional?' . he continued: 'for me, one of the issues with "diy braces" is that it offers just one narrow solution when there may be a more appropriate one for the patient. the value of informed choice cannot be over-estimated. ' this is a huge step that should, hopefully, raise awareness of the dangers of direct to consumer orthodontics to the general public. a. alkadhimi, london, uk https://doi.org/10.1038/s41415-020-1684-6 sir, to determine the use and perceived benefit of webinars and online learning, a brief survey was sent to dentists across the uk; 50 responses were received from a mix of those working in general dental practice, hospital and community. prior to the outbreak of covid-19, only 17% of dentists had attended a webinar, however, within the last six weeks 64% have done so. for dentists who have engaged with these, 60% had attended five or more, demonstrating a proactive attitude towards learning; 94% found the content beneficial and 92% stated they would attend a webinar in the future, once social distancing measures have been relaxed. interestingly, although there is a clear and obvious advantage of face-to-face teaching, 35% would prefer online over face-to-face. we believe this demonstrates the advantages of online education and a possible shift in the future of teaching. regarding face-to-face study days, dentists felt the biggest barrier to attending was the ability to get time off work (71%), closely followed by the location, and costs involved with travelling, course fees and hotels. taking time away from clinical practice has obvious financial implications whereas sir, recently, a friend messaged asking my opinion on a 'diy ultrasonic tooth cleaner' after deciding that since the dentist is closed she may need to take dental care into her own hands. i was surprised to discover that commercially available is an 'electric plaque reduction tool' . these tools were advertised as being designed to effectively reduce dental plaque, dental calculus, hard tartar, stains and help decrease bacteria in the mouth. the design appears similar to that of an electric toothbrush but with a sharp, scaler tip attached rather than a brush head. these devices don't produce water; however, some are advertised as capable of vibrating at a rate of 12,000 times per minute. this tool if used incorrectly has serious potential to cause damage to the periodontal tissues and dentition and i advised my friend accordingly. it is worthwhile readers being aware of these kinds of tools that are available to patients so that the appropriate advice can be given. s. pahal, bristol, uk https://doi.org/10.1038/s41415-020-1685-5 sir, i enjoyed the paper entitled experience of listening to music on patient anxiety during minor oral surgery procedures: a pilot study by gupta and ahmed 1 and feel that music can be an invaluable tool in calming patients during procedures. using music as medicine is a safe and non-pharmacological method   of managing anxiety during complex dental procedures and the potential for research in this area is wide. regarding the study, i pose a question to the authors: i was interested to read that almost half of the participants (48%) reported that music made communication easier and wonder if they could elaborate on this? in my experience, when patients wear headphones and listen to music for distraction and relaxation, communication is negatively affected to some degree in terms of gaining the patient's attention and i wondered how the authors overcame this challenge. additionally, it is no secret that dentistry can be a stressful career, now more than ever due to the coronavirus. stress is believed to be one of the major factors that negatively affect our health, contributing to conditions such as cardiovascular disease, chronic pain and burn out to name but a few. 2 the calming and stress reducing effects of listening to music have been widely studied and this simple and cost-effective method of relaxation is something easily accessible to all members of the dental team. well-being is always an important consideration and fundamental to happiness and good mental health. there are so many benefits linked to the simple pleasure of listening to our favourite music and i would encourage my colleagues and peers to think about capitalising on these benefits. our study only investigated the effect on the patient of music via headphones, not on the dentist. we would agree that dentistry is a stressful profession, but stress is generally hard to measure and includes so many variables outside clinical factors. at our teaching and training centre in birmingham, we do not play music as this can lead to distraction for our students, trainees and staff. moreover, playing music in a hospital or clinic does require a licence. as our project suggests patients are welcome to bring their own music using their smart phone and play various tracks using their own headphones. https://doi.org/10.1038/s41415-020-1683-7 behavioural therapy? how long is the wait? how many courses of antibiotics can be given for recurrent abscesses before it becomes unacceptable? the alternative is to accept the patient will undergo repeat gas and never be encouraged to take responsibility for their dental health. i suspect that as a result of inability or unwillingness of these patients to be treated, and given the options within the existing service, what used to be restorable teeth will be left to cavitate and inevitably become unrestorable, with the same number of teeth or more being extracted in say 12 months' time, compared to if the decision was made to prophylactically extract the teeth with restorable caries at initial consultation, albeit at a different degree of disease progression. as if being bounced backwards and forwards within the health care system is not discouraging enough, in the meantime, who has a responsibility of care for these patients when they are in pain or develop abscesses, and where do they go? m. wooi, liverpool, uk https://doi.org/10.1038/s41415-020-1682-8 where do they go? sir, as a dct3 in oral surgery i have seen several patients referred for removal of teeth under general anaesthetic (ga) due to dental anxiety. whilst this is possible for a tier 3 oral surgery service, these patients usually also present with multiple restorable carious teeth which ideally should be restored prior to listing them for the ga, which we unfortunately are not commissioned to provide under this service. the treatment plan usually ends up advising that their gdp refer them for restorations under iv sedation in a community dental practice (tier 1) service and be made dentally fit before they get re-referred back to us, solely for the extractions. if this is not possible, the only other option is every single carious tooth will have to be extracted in the same course of treatment under ga, which usually adds up to a significant number for a relatively young adult. this problem is compounded by the common presentation that these patients are usually dental needle phobic, who almost certainly will not tolerate needle plus drilling under single drug iv sedation alone. in some areas they may be able to be referred to a special care service, but these are very limited, and the patients may not fulfil the referral criteria. the behavioural decision as to whether these patients 'will not tolerate needle' or 'cannot tolerate needle' becomes so fine that it may be up to the discretion of the clinician on the day. can they be referred and accepted to undergo cognitive sir, chemical dissolution of tooth hard tissue due to exposure to an acidic environment, namely erosion, leads to tooth surface loss (tsl) with an estimated mean global prevalence of erosion in both primary (30%-50%) and permanent dentition (20%-45%). 1 extrinsic acids are a major cause of dental erosion and are mainly due to acidic foods and drinks consumed routinely. while most consumers are unaware of the potential harm to their teeth of these items, the same approaches employed to reduce unhealthy food intakes (eg sugar, fat, etc), could also help to reduce tsl. 2,3 front of pack food labelling (fopl) has long been used to help consumers to make informed purchases, although policies are not consistent between different regions and countries. fopl commonly include types and/or relative amounts of fats, starch, salt, protein and fibre. 4 it is important for manufacturers to also include acidity of foods and drinks in the labelling. this information should be presented in a manner that is understandable to the general public and not by simply indicating ph value of the products. a traffic experience of listening to music on patient anxiety during minor oral surgery procedures: a pilot study effects of music interventions on stress-related outcomes: a systematic review and two meta-analyses key: cord-013116-n7auvqh3 authors: srinivas, a.; moshkun, c.; darcey, j. title: testing the limits of udcs date: 2020-10-09 journal: br dent j doi: 10.1038/s41415-020-2226-y sha: doc_id: 13116 cord_uid: n7auvqh3 nan sir, a 77-year-old male attended the emergency dental clinic at the university dental hospital of manchester (udhm). the main complaint was an ongoing, nonspecific facial pain of the right face following extraction of the 16 two months previously. history revealed that the 17 had been removed four months prior to presentation due to similarly vague symptoms. the pain failed to settle so the 16 was subsequently removed. the patient reported both teeth to have become mobile prior to extraction. ten days after the extraction of the 16 he presented at udhm with ongoing persistent symptoms. he had already begun a course of antibiotics and was using chlorhexidine mouth rinses prescribed remotely via an urgent dental centre (udc). radiographs ruled out any retained root fragments but clinical examination revealed an area of exposed bone. conservative management advice was reiterated and two weeks later, the patient was seen for a review. the pain had reduced but there was still discomfort in the area and the patient reported it to feel sharp on his tongue. the socket had epithelialised but a small fragment of bone was present and this was removed under local anaesthetic. he was advised to return to his gdp for review. the patient contacted udhm six weeks later with ongoing pain and a face-to-face review was arranged. in that time he had not been offered a face-to-face review but rather been given a further two courses of antibiotics after remote udc consultations. he presented with moderate discomfort, radiating around the right side of his face which he was able to manage with simple analgesia. he had no extra-oral swelling, temperature sensitivity or tenderness to chew. he reported no history of swellings. examination revealed friable red and white speckled tissue fungating from the socket with adjacent ulceration extending around the 15 mesially and 17 region distally. there was an area of indurated tissue extending 1 cm into the hard palate with rolled borders. he had no risk factors in his medical or social history. a provisional diagnosis was made of squamous cell carcinoma and an urgent biopsy was taken. histopathology confirmed moderately differentiated scc and he has been referred via an urgent pathway to maxillofacial services. reflecting back over this patient's history and clinical encounters there were signs that may have pointed towards a nonodontogenic diagnosis. certainly, it would appear there was no indication for repeated courses of antibiotics. the picture is further complicated by the number of clinical and remote contacts with different clinicians. we hope this may serve as a timely reminder of the limitations of remote consultations and the possible consequences of a lack of continuity of care in any one setting. a. srinivas, c. moshkun, j. darcey, manchester, uk https://doi.org/10.1038/s41415-020-2226-y missing a serious diagnosis or misdiagnosing. this has also been noted by the medical profession, particularly around telephone consultation, where clinician experience and skill are deemed to reduce risk. 4 from my experience working in hospital oral surgery and oral medicine services during the pandemic, a multitude of factors inform a risk assessment that influences whether a patient is seen remotely or face-to-face, including: patient complaints/ concerns about their oral health, nhs trust policy, patient wishes, type of oral disease/problem (confirmed or suspected), patient's accessibility to a device for a remote consultation, distance a patient would travel to our clinic, prevalence of covid-19, patient's general health and vulnerability to covid-19. furthermore, remote consultation requires a different communication approach and arguably more thorough history taking to triage those that require a face-to-face appointment. it seems inevitable that remote consultation will become a permanent and useful element of dentistry owing to the potential for improved efficiency and accessibility. with the start of the academic year upon us, as dental hospitals and schools, we will need to consider how to teach this new skill set to our students and trainees. this could involve utilisation of observation, role play and peer review to develop both remote communication skills and competencies in facilitating a joint decision with patients about the most appropriate consultation mode. m. dobson, dundee, uk teledentistry from a patient perspective during the coronavirus pandemic letters to the editor send your letters to the editor, british dental journal, 64 wimpole street, london, w1g 8ys. email bdj@bda.org. priority will be given to letters less than 500 words long. authors must sign the letter, which may be edited for reasons of space.  british dental journal | volume 229 no. 7 | october 9 2020 397 upfront key: cord-032698-ev8gylpf authors: fakhruddin, k. s.; ngo, h. c.; samaranayake, l. title: pandemic paediatrics date: 2020-09-25 journal: br dent j doi: 10.1038/s41415-020-2171-9 sha: doc_id: 32698 cord_uid: ev8gylpf nan sir, paediatric patients presenting with irreversible pulpitis and related afflictions need urgent care delivered through the use of aerosol-generating rotary instrumentation and air/water syringes. these procedures increase the probability of airborne microbial transmission, such as severe acute respiratory syndrome coronavirus 2 (sars-cov-2). two recently published articles in your journal highlighted the utility of silver diamine fluoride (sdf) and potassium iodide (sdf/ki) application, and paediatric patients audit attending emergency care for irreversible pulpitis symptoms during the current coronavirus disease 19 (covid-19) pandemic. 1, 2 children are believed to exhibit only mild sars-cov-2 symptoms or they could be asymptomatic carriers and hence, the care pathway has been sensibly devised to treat every child as a potential covid-19 positive patient. 2 thus, to limit bioaerosol risks, the contemporary treatment algorithm includes the use of pre-procedure oral rinse with 1% hydrogen peroxide or povidone-iodine 3 and the use of dental dam, as well as high-volume suction. nevertheless, the use of mouthwash is contraindicated in children younger than sixyears-old owing to their immature, fine-motor control and oral muscle reflexes, required to properly spit out mouthwashes. 4 additionally, both in young and older children, the saliva laden expectorate laced with the virus itself may pose a threat of sars-cov-2 transmission, if it is not properly collected, contained, and disposed of. it is known that the cavitated dental lesion is a thriving biome of bacterial, fungal, and viral flora. thus, pre-treatment of the cavitated lesions with an antimicrobial, prior to high speed instrumentation, is likely to diminish the aerosolisation of viral particles and their inhalation by dental personnel. there is now ample data to indicate the viricidal potential of both silver and iodide containing formulations. 3, 5, 6 hence, we wish to propose that, for children younger than six years of age, the swabbing of the procedure site with gauze soaked in povidone-iodine should be followed by application of sdf and ki. the latter, while potentiating the antimicrobial effect, can also be an extremely effective dentine desensitiser. 1 in addition, desensitising the exposed operative focus of highly sensitive dentine could mitigate stress, and increase compliance and facilitate paediatric patient management. potential dental team role in supporting the delivery of a flu vaccination programme. 1 in the united states, minnesota and illinois allow dentists to administer vaccines, but only to protect against the flu and only in adult patients. in 2020, oregon becomes the first state in the united states to allow dentists to offer any vaccination to a patient. 2 in scotland, nhs dental contractors (dentists and dental bodies corporate) can opt in to participate in the 2020/21 flu vaccination programme. participation will be agreed locally by nhs boards and area dental committees, depending on the overall requirements to deliver the programme. a one-off participation fee of £250 will be offered to each contractor and in addition, a flat fee of £8.27 will be paid per immunisation. 3 nhs education for scotland is developing learning resources to support delivery of the flu vaccination programme. this is in line with the guidance from the general dental council that dental professionals must be trained and competent for all skills and treatment that they undertake. 3 indemnity cover for dentists will be provided by the scottish government. other members of the dental team will not be allowed to deliver vaccinations. c. a. yeung, bothwell, uk silver diamine fluoride -an overview of the literature and current clinical techniques covid-19 pandemic: the first wave -an audit and guidance for paediatric dentistry povidone iodine gargle and mouthwash pediatric dentistry: infancy through adolescence enhancement of respiratory mucosal antiviral defenses by the oxidation of iodide silver nanoparticles as potential antiviral agents dental team immunisation could vaccines come from your dentist? not yet 2020)12: influenza vaccination programme -2020/21 https://doi.org/10.1038/s41415-020-2183-5 sir, delivering the seasonal flu vaccination programme this year will be more challenging than in previous years due to the impact of covid-19. i fully support the proposal by serban et al. regarding the comment letters to the editor send your letters to the editor, british dental journal, 64 wimpole street, london, w1g 8ys. email bdj@bda.org. priority will be given to letters less than 500 words long. authors must sign the letter, which may be edited for reasons of space.  british dental journal | volume 229 no. 6 | september 25 2020 325upfront key: cord-270051-rs3cz9lq authors: wordley, v.; shah, s.; thompson, w. title: increased antibiotics use date: 2020-09-11 journal: br dent j doi: 10.1038/s41415-020-2128-z sha: doc_id: 270051 cord_uid: rs3cz9lq nan nhs dentistry in england in 2018 and 2019. the number of antibiotics dispensed each month by community pharmacists in england relating to nhs dental prescription forms from january 2018 to may 2020 is given in figure 1 . 3 this shows antibiotic use in may 2020 was a clear outlier compared to the previous 28 months being 18.4% higher than in may 2019 (n = 267,719 and 226,188 respectively). interestingly, antibiotic use in april 2020 was slightly higher than the previous april but still within the normal range for the period of study. this is despite the significantly poorer access to dentistry (only around 7,500 patients were seen at designated urgent dental centres [udcs] across england) compared to may when the capacity of these centres increased and saw over 27,000 patients. 4 a range of non-clinical factors are known to be associated with dentists' decision-making about antibiotics prescription for acute conditions. 2 antibiotics may have been used: • as a 'quick fix' to avoid the life-time impact of an unnecessary extraction, in anticipation that agps might soon be permissible in general dental practices • because dentists felt pressured by some patients for antibiotics, irrespective of their efficacy or appropriateness for treating toothache • because of difficulties diagnosing a patient's condition remotely prompting a 'just in case' approach through concerns of life-threatening deterioration without treatment • as some udcs were requiring patients to have tried antibiotics before accepting referral for face-to-face care, highlighting system and process impact on antibiotic prescribing. finally, the nhs may have seen an influx in patients who might otherwise receive care privately, resulting in an increase in nhs dental prescriptions as, anecdotally, not all practices were open for telephone triage during april and may 2020. examination of figures for the remainder of 2020 will reveal any enduring impact that covid interventions may have on dental antibiotic prescribing and in identifying optimisation of future dental antibiotic stewardship. v sir, pre-covid, dentists were responsible for about 10% of all antibiotic prescribing worldwide. 1 at the onset of the pandemic most dental practices were restricted to giving advice, analgesia and antibiotics (aaa). reduced access to dental care and an inability for dentists to provide dental procedures increases dental antibiotic prescribing. 2 a large increase in dental antibiotic use in england during april and may 2020 was widely anticipated and so we undertook a rapid analysis comparing antibiotic use across sir, the pre-visit triage, which practices are advised to do, will preclude any proven or probable covid-19 patients from attending a practice, leaving only the possible, undiagnosed cases as posing a risk of bringing this infection into a practice. our city council produces weekly updates of new cases, which gives a good indication of the level of infection in the population which our practice serves. when this figure is combined with the average number of patients that we have seen each week, since lockdown was eased, and the local population, this enables us to quantify the risk of us seeing an undiagnosed covid-19 patient in the practice. last week, this indicated that the average risk of seeing such a patient was one every 1,066 weeks, or one every 22.2 years. there are plenty of generalisations used in that calculation but it is certainly food for thought. povidone iodine covid-19: povidone-iodine intranasal prophylaxis in front-line healthcare personnel and inpatients (piippi). clinicaltrials.gov practical use of povidone-iodine antiseptic in the maintenance of oral health and in the prevention and treatment of common oropharyngeal infections stable compositions of uncomplexed iodine and methods of use references 1. fdi. antibiotic stewardship in dentistry -fdi policy statement: fdi world dental federation factors associated with prescribing of systemic antibacterial drugs to adult patients in urgent primary health care, especially dentistry personal communication re: dr1242 re: request for information key: cord-030556-usyvz5fj authors: dave, m.; ariyaratnam, s.; dixon, c.; patel, n. title: open-book examinations date: 2020-08-14 journal: br dent j doi: 10.1038/s41415-020-2008-6 sha: doc_id: 30556 cord_uid: usyvz5fj nan 1. gov uk. press release: new obesity strategy. available at https://www.gov.uk/government/news/new-obesity-strategy-unveiled-as-country-urged-to-lose-weightto-beat-coronavirus-covid-19-and-protect-the-nhs (accessed july 2020). https://doi.org/10.1038/s41415-020-2006-8 themselves have often had little knowledge about the importance of optimising their dental health as part of their medical condition and some have not accessed dental care for many years. this experience has highlighted that dentistry plays an important role within the integrated care system but is currently often overlooked. as we look to the future, and the restoration of dental services, the profession needs to work with stakeholders to ensure that the importance of oral health as part of holistic healthcare is fully understood and high on the public health agenda. a sir, as a specialist registrar in training in special care dentistry i have been working in an urgent dental care (udc) hub providing care for shielded, vulnerable and covid positive patients in a rural county. we have had a considerable number of patients referred to the udc with significant complex medical conditions and medication regimes. referrals have included pre-transplant patients, oncology patients undergoing active treatment, complex liver and kidney disease, an array of rare diseases and numerous rheumatology patients taking a range of disease modifying medications. many patients have required additional blood tests, investigations and medication reviews prior to undertaking dental treatment inevitably requiring communication with multiple medical specialities. a great majority would have benefited greatly from a dental examination prior to starting treatments such as bisphosphonates, chemotherapy or radiotherapy. many are now in a compromised position where risks of conditions such as medication-related osteonecrosis of the jaw is high. the patients sir, the uk curricula in dentistry is set by the general dental council with universities required to provide assurances that intended learning objectives (ilos), clinical and nonclinical milestones and competencies have been satisfactorily achieved. assessments in these courses are longitudinal and end of year examinations assess different sections of the ilos to demonstrate evidence-based practice in clinical scenarios and decision making mirroring the clinical environment. traditionally, closed book examinations such as multiple-choice questions, where learners are not permitted to have any supportive material with them, are the preferred format for uk dental courses. the covid-19 national lockdown resulted in re-structuring of assessments to open-book formats so learners could complete their examinations at home and has provided a novel opportunity to reflect on examination practices. 1 in open-book examinations, learners have access to supportive material such as revision notes, books and online resources thereby testing the application of knowledge rather than its recall. 2 studies have shown that learners revising for open-book examinations prepare by proactively understanding the content and its application for problem solving, thereby encouraging deep learning. 3 learners have also reported feeling less anxious about exam preparation, which is reflected in significantly higher test scores. 4, 5 nonetheless, these examinations can test information retrieval rather than knowledge and this is a well-recognised limitation. more sir, loss of smell (anosmia) and loss of taste (ageusia) are symptoms that were identified in covid-19 patients at the early stage of illness. 1 these symptoms may last from a few days to few weeks and may be associated with continuous viral shedding. 2 dental professionals should be aware that the continuous impairment of olfactory and gustatory functions after 14 days of quarantine and onset of the symptoms may indicate incomplete recovery, that a recently recovered covid-19 patient may still be carrying the viral load and risk of virus transmission should not be excluded. with such an hypothesis in mind, it is recommended to postpone dental treatment of a recently recovered covid-19 patient who still suffers from these persistent symptoms until complete resolution. b. tarakji medical students take final exams online for first time, despite student concern. the guardian 22 influence of open-and closed-book tests on medical students' learning approaches examining the testing effect with open-and closed-book tests effect of access to an electronic medical resource on performance characteristics of a certification examination: a randomized controlled trial test-enhanced' focused self-directed learning after the teaching modules in biochemistry covid-19 in south korea -challenges of subclinical manifestations asymptomatic infection and atypical manifestations of covid-19: comparison of viral shedding duration key: cord-309493-mp43qa7w authors: carr, s. title: special care and new environments date: 2020-06-26 journal: br dent j doi: 10.1038/s41415-020-1786-1 sha: doc_id: 309493 cord_uid: mp43qa7w nan https://doi.org/10.1038/s41415-020-1794-1 sir, patients with autism and other special care needs often rely on familiar surroundings, processes and faces when attending the dentist to reduce the sensory burden and anxiety of being in the dental environment. any change to the 'routine' of attending may present such patients with difficulties that the dental team should have awareness of and be sensitive to. we must make every effort to prepare patients for the changes to the dental environment that they are used to attending such as the increased use of ppe. sending photographs and advice of how layouts and processes may have changed within the practice and what to expect regarding ppe and infection control procedures ahead of their appointment to patients and carers could prove invaluable in maintaining both attendance for this potentially higher risk group, as well as talking through any new steps during their visit or procedure to maximise compliance. technology can also be utilised to facilitate this, such as 360 degree photographs or video tours on practice websites or social media. although aerosol generating procedures would ideally be carried out in a single visit, this may not be possible or practicable for this patient group. any additional barriers to attending for regular preventive dental care could have significant longer term risks to the dental health of this already vulnerable patient cohort. a decrease in regular professional preventive input risks increasing the need for invasive procedures and sedation or general anaesthesia, in turn increasing risks to both dental and general health. we must therefore do everything we can to minimise sir, a recent letter in your journal by challacombe et al. highlighted the potential of povidone iodine (pvp-i) mouthwash and nasal spray in reducing the risk of cross-infection of covid-19 among the dentists and their assistants. 1 the evidence used was based on in vitro data of pvp-i's virucidal activity against coronaviruses such as sars-cov and mers-cov. here, we demonstrate in vitro virucidal activity of an oral pvp-i product against sars-cov-2, the virus causing covid-19. betadine gargle and mouth wash in two concentrations, undiluted (pvp-i 1% w/v) and at a 1:2 dilution (pvp-i 0.5% w/v) was tested for virucidal activity (≥4 log10 reduction in viral titres) against sars-cov-2 in both clean (0.3 g/l bsa) and dirty (3.0 g/l bsa + 3 ml/l human erythrocytes) conditions at time points of 15, 30 and 60 seconds in a bsl-3 laboratory of the tropical infectious diseases research and education center (tidrec), university of malaya, malaysia. the sars-cov-2 was isolated and propagated in vero-e6 cells in tidrec. the cytotoxicity of the product to the vero-e6 cells was evaluated and taken into account when performing the kill time assay. virus kill time assay was performed based on the established en14476 methodology. 2 virus titres were calculated as 50% tissue culture infectious dose (tcid50/ml) using the spearman-karber method. 2 the study demonstrated that undiluted pvp-i achieved >5 log10 reduction in the virus titres at 15, send your letters to the editor, british dental journal, 64 wimpole street, london, w1g 8ys. email bdj@bda.org. priority will be given to letters less than 500 words long. authors must sign the letter, which may be edited for reasons of space. british dental journal | volume 228 no. 12 | june 26 2020 upfront povidone iodine in vitro bactericidal and virucidal efficacy of povidone-iodine gargle/mouthwash against respiratory and oral tract pathogens being a front-line dentist during the covid-19 pandemic: a literature review australian dental association. managing covid-19 guidelines key: cord-011775-2hg82nuy authors: nan title: bda updates its returning to work toolkit for members date: 2020-06-26 journal: br dent j doi: 10.1038/s41415-020-1813-2 sha: doc_id: 11775 cord_uid: 2hg82nuy nan as far back as 1785, immanuel kant advised us to treat people 'never merely as a means to an end, but always at the same time as an end. ' 1 throughout the covid-19 crisis, those in control appear to have ignored this sage advice with both dental professionals and patients increasingly used as pawns in a political game. and so, with just ten days' notice, those of us in practice were sent back to work. since then, we've been bombarded with numerous sets of sops and back to work guidance. experts and self-appointed gurus have flooded the internet with words of wisdom, some much wiser than others. i like a guideline and a protocol, but even i think that this has been a case of information overload. throughout the covid-19 crisis, the amount of, often conflicting, advice thrown towards the dental community has caused confusion, dismay and anger. some have even suggested that we should have hard and fast rules put in place by our various regulators to ensure what we are doing is correct. apart from this being beyond their collective remits, this is a bad idea. once we set a precedent for regulators to provide strict guidelines, where do we stop? currently, we're in a relatively enviable position of being allowed to practise dentistry how we see fit, within reason. allowing regulators to dictate how we're allowed to deliver those treatments leads to a much less autonomous profession. it also makes it much easier for claims of substandard practice to be levelled at any one of us who doesn't follow those guidelines. at a time when the profession feels under fire, this will only exacerbate the ill will towards those that govern us. it feels as if that ill will has increased significantly since lockdown measures were enacted. the vitriol of the profession has mainly been directed at those in charge, and specifically the cdo of england. the messages coming from our chief have not always been clear, and one would hope there would be lessons to be learned from this, especially in regards to engaging with the profession using social media. significant sectors of the profession have felt alienated throughout the covid-19 crisis, with no support from the government or their leaders. from this, new alliances have formed for the betterment of all. the profession as a whole should also be looking inwards at itself to reflect on the nature of the discourse we have participated in recently. it's worth remembering that the cdo is as much a political position as one of a leader of healthcare. the position lends itself to be as much of a pawn in the political strategy as the rest of the profession. the bitterness of much of the commentary has been unpleasant to see, let alone be on the receiving end of. i wonder if the gender of the cdo has played any part in this? now is not the time to let our shield of professionalism down. now is the time to reinforce it and become united for positive change. the british dental association (bda) has published an updated edition of its toolkit for returning to face-to-face care. it will support members and their teams to resume dental practice as safely and efficiently as possible. the toolkit will help dental teams implement the changes needed to gear up to providing appropriate treatments at appropriate times. it is for practices in england; the bda is working on versions for the devolved nations in line with developing frameworks. this latest version of the toolkit [4 june] has been updated with essential information on ppe, fit-testing, respiratory protective equipment (rpe) and the furloughed workers scheme. members can download the toolkit and related resources at: https:// www.bda.org/advice/coronavirus/pages/returning-to-work.aspx. a recently published paper in the korean journal of medical science, 'clinical significance of a high sars-cov-2 viral load in the saliva' , demonstrates the in vivo activity of chlorhexidine as a mouthwash against viruses. 1 it suggests that the in vivo activity will last for two hours and is gone by four (and not repeatable when the mouthwash is tried again at day six) but also confirms the very high levels of sars-cov-2 in saliva and in the nose. the general conclusion from studies of antiviral activity of mouthwashes in vitro suggests that chlorhexidine is not as effective as povidone iodine, but this study suggests that it does have antiviral activity and could be considered as a backup. groundwork of the metaphysics of morals (1785) clinical significance of a high sars-cov-2 viral load in the saliva key: cord-320393-9bgxct3z authors: scott, d.; hogan, t.; john, j. title: rubber dam evidence date: 2020-08-14 journal: br dent j doi: 10.1038/s41415-020-2011-y sha: doc_id: 320393 cord_uid: 9bgxct3z nan https://doi.org/10.1038/s41415-020-2011-y sir, we are writing to draw attention to some interesting research that questions the validity of the disulfiram-like reaction between metronidazole and alcohol. this reaction is the reason the british national formulary 1 advises to avoid alcohol during and for 48 hours after taking metronidazole. giving this advice is standard practice amongst most clinicians. disulfiram is a drug used to discourage alcohol consumption. its interaction with alcohol leads to acetaldehyde accumulation causing symptoms such as skin redness, palpitations, nausea, vomiting, headache and in severe cases circulatory collapse. 2 the disulfiram-like reaction of metronidazole and alcohol is said to be similar, and was traditionally explained by the same mechanism, although this now seems to be incorrect. 2, 3, 4 its frequency is unclear as figures vary between 0 and 100%. 5 its validity has been repeatedly questioned in the modern literature. serious reactions including at least one death have been attributed to it, 3,5 although at least some of these have been disputed. 3 a number of clinical studies and reviews have found evidence of the existence of this interaction to be absent or weak. 2, 3, 4, 6 although we do not seek to promote alcohol intake, the advice to abstain completely will restrict patient lifestyle for that period. there are situations such as alcohol dependent patients where this could be especially problematic, so settling this is important. overall the evidence for this reaction appears to be weak at best. it appears likely that the concern attached to it is overstated. the purported reaction could actually be an alcohol-independent side effect of metronidazole, an effect of alcohol, or disease -possibilities not adequately eliminated by the studies. 2 furthermore, the term 'disulfiram-like' is a misnomer, at least in a biochemical sense, as it seems that any such reaction does not occur through the same mechanism as disulfiram. conversely, no definite evidence is presented that this reaction does not occur -perhaps it occurs only in a small subgroup. the aim of this letter is not to suggest we, as clinicians, stop advising patients to avoid alcohol whilst on metronidazole. rather all clinicians should be alert to its weak evidence base and be ready to question and reject long-held beliefs and mantras such as this should new evidence emerge. sir, we read with interest the correspondence by c. emery and r. chate (bdj 2020; 229: [4] [5] advocating the use of rubber dam as an infection control precaution. in response to the covid-19 pandemic, we undertook a rapid literature review on the effectiveness of rubber dam in reducing the risk of transmission of microbial pathogens during dental aerosol-generating procedures (agps). six studies 1,2,3,4,5,6 produced a broad consensus that the use of rubber dam during dental agps is effective at reducing the spread of spatter by 33%, as well as reducing surface contamination with bacteria by 80-99% at a distance of up to one metre. one exception 7 suggested that rubber dam could deflect spatter onto the dentist's head; however, this is unlikely to be of clinical significance provided the dentist wears appropriate personal protective equipment. unfortunately, no studies investigated the effectiveness of rubber dam in preventing transmission of viral pathogens. while it might be reasonable for practical purposes preliminary study -air contamination with microorganisms during use of the air turbine handpiece aerosols produced by dental instrumentation the efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment the efficacy of rubber dam isolation in reducing atmospheric bacterial contamination efficacy of rubber dam isolation as an infection control procedure in paediatric dentistry evaluation of the spatter-reduction effectiveness of two dry-field isolation techniques the effect of rubber dam on atmospheric bacterial aerosols during restorative dentistry metronidazole -interactions er det virkelig farlig å kombinere metronidazol og alkohol? do ethanol and metronidazole interact to produce a disulfiram-like reaction? key: cord-011776-0qdxqu22 authors: nan title: chlorhexidine has an antiviral effect against viruses date: 2020-06-26 journal: br dent j doi: 10.1038/s41415-020-1812-3 sha: doc_id: 11776 cord_uid: 0qdxqu22 nan as far back as 1785, immanuel kant advised us to treat people 'never merely as a means to an end, but always at the same time as an end. ' 1 throughout the covid-19 crisis, those in control appear to have ignored this sage advice with both dental professionals and patients increasingly used as pawns in a political game. and so, with just ten days' notice, those of us in practice were sent back to work. since then, we've been bombarded with numerous sets of sops and back to work guidance. experts and self-appointed gurus have flooded the internet with words of wisdom, some much wiser than others. i like a guideline and a protocol, but even i think that this has been a case of information overload. throughout the covid-19 crisis, the amount of, often conflicting, advice thrown towards the dental community has caused confusion, dismay and anger. some have even suggested that we should have hard and fast rules put in place by our various regulators to ensure what we are doing is correct. apart from this being beyond their collective remits, this is a bad idea. once we set a precedent for regulators to provide strict guidelines, where do we stop? currently, we're in a relatively enviable position of being allowed to practise dentistry how we see fit, within reason. allowing regulators to dictate how we're allowed to deliver those treatments leads to a much less autonomous profession. it also makes it much easier for claims of substandard practice to be levelled at any one of us who doesn't follow those guidelines. at a time when the profession feels under fire, this will only exacerbate the ill will towards those that govern us. it feels as if that ill will has increased significantly since lockdown measures were enacted. the vitriol of the profession has mainly been directed at those in charge, and specifically the cdo of england. the messages coming from our chief have not always been clear, and one would hope there would be lessons to be learned from this, especially in regards to engaging with the profession using social media. significant sectors of the profession have felt alienated throughout the covid-19 crisis, with no support from the government or their leaders. from this, new alliances have formed for the betterment of all. the profession as a whole should also be looking inwards at itself to reflect on the nature of the discourse we have participated in recently. it's worth remembering that the cdo is as much a political position as one of a leader of healthcare. the position lends itself to be as much of a pawn in the political strategy as the rest of the profession. the bitterness of much of the commentary has been unpleasant to see, let alone be on the receiving end of. i wonder if the gender of the cdo has played any part in this? now is not the time to let our shield of professionalism down. now is the time to reinforce it and become united for positive change. the british dental association (bda) has published an updated edition of its toolkit for returning to face-to-face care. it will support members and their teams to resume dental practice as safely and efficiently as possible. the toolkit will help dental teams implement the changes needed to gear up to providing appropriate treatments at appropriate times. it is for practices in england; the bda is working on versions for the devolved nations in line with developing frameworks. this latest version of the toolkit [4 june] has been updated with essential information on ppe, fit-testing, respiratory protective equipment (rpe) and the furloughed workers scheme. members can download the toolkit and related resources at: https:// www.bda.org/advice/coronavirus/pages/returning-to-work.aspx. a recently published paper in the korean journal of medical science, 'clinical significance of a high sars-cov-2 viral load in the saliva' , demonstrates the in vivo activity of chlorhexidine as a mouthwash against viruses. 1 it suggests that the in vivo activity will last for two hours and is gone by four (and not repeatable when the mouthwash is tried again at day six) but also confirms the very high levels of sars-cov-2 in saliva and in the nose. the general conclusion from studies of antiviral activity of mouthwashes in vitro suggests that chlorhexidine is not as effective as povidone iodine, but this study suggests that it does have antiviral activity and could be considered as a backup. groundwork of the metaphysics of morals (1785) clinical significance of a high sars-cov-2 viral load in the saliva key: cord-011773-vboa8xn9 authors: richards, j. a.; beaumont, i.; beech, a. n. title: coronamolars? date: 2020-06-26 journal: br dent j doi: 10.1038/s41415-020-1803-4 sha: doc_id: 11773 cord_uid: vboa8xn9 nan acceptance of the virtual clinic concept in maxillofacial surgery: a departmental survey. br j oral maxillofac surg 2020; 58: 458-461. https://doi.org/10.1038/s41415-020-1802-5 dental education sir, the last 18 months of dct in oral and maxillofacial surgery have highlighted challenges and complications presented by facial aesthetic treatments. a mysterious alteration in the soft tissue profile of a pre-operative orthognathic case was explained when the patient revealed a recent use of filler injections. a similarly difficult clinical assessment involved a mucocele of the lip, in which the patient admitted to lip enhancement injections a few weeks prior to the swelling appearing. an infected facial sebaceous cyst in a history of 'silhouette face lifts' , which reportedly involved insertion of needles into the face, raised questions as to appropriate follow-up and with whom responsibility should lie to identify adverse outcomes. reality tv, notably love island and 10 years younger in 10 days, may reflect increasing demand for aesthetic treatments. dentists advertising themselves as an 'aesthetic doctor' seem commonplace on social media platforms, widening accessibility to these services. this may be prompting a culture of self-identifying perceived unappealing physical traits and fuelling a vulnerability towards a desire to alter facial appearance. the british association of aesthetic plastic surgeons warn that 'people who struggle with their psychological health can feel pressured to turn to "quick fix" procedures to improve their appearance' and recommend pre-treatment psychological assessments. 1 with mental health becoming increasingly topical, i question how equipped dentists are in assessing psychological wellbeing in this context. conditions such as body dysmorphia could be implicated and missed with damaging repercussions. i am unaware of any dental schools teaching facial aesthetic treatments including dermal fillers as part of the undergraduate course. it is therefore somewhat unsettling that dentists can attend a one-day course before providing treatments such as 'nonsurgical rhinoplasty' when they have likely had no training on this in their professional degree. increasingly concerning is the practice of non-dentists providing facial aesthetic treatments, such as pharmacists, nurses and midwives, who will have limited, if any, knowledge or consideration for oro-facial anatomy and pathology. these practitioners may underestimate the scope for serious complications alongside varied experience in obtaining informed consent. the gdc state that you must 'undertake appropriate additional training to attain the necessary competence' and you 'must not mislead patents into believing that you are trained and competent to provide other services purely by the virtue of your primary qualification'. 2 what constitutes appropriate additional training and how practitioners can evidence competence is open to interpretation. it seems obvious that change is required in the regulations surrounding facial aesthetic procedures, particularly training of practitioners and steps to protect psychological health. it may be sensible to include such training within the bds degree given the large proportion of dentists going on to provide these services. j. virdee, harrow, uk cosmetic surgery trends: reduction in overall numbers as industry associations campaign for education and tighter regulation gdc guidance on advertising we have all been taught in our undergraduate training about 'mulberry molars' from maternal syphilis and hypoplastic first molar teeth in which maternal viral infection has been implicated. we wonder, due to the current covid-19 global health crisis, will we see 'coronamolars' in six or so years' time and what will their form take? https://doi.org/10.1038/s41415-020-1803-4 sir, it was interesting to see how undergraduate orthodontic teaching has progressed since the early computer assisted learning (cal) pioneers professor chris stephens and penny grigg in the 1990s. 1, 2 chris pioneered the use of computers not only in orthodontic teaching, but also early ai in treatment planning and teledentistry for orthodontic advice. 3 but, way back then it was not known as blended learning, key: cord-026764-eag13h3p authors: sumner, o.; datta, s. title: age-appropriate antibiotics date: 2020-06-12 journal: br dent j doi: 10.1038/s41415-020-1723-3 sha: doc_id: 26764 cord_uid: eag13h3p nan of care to those with chronic conditions. the case for patients with sle could represent one of many interruptions to treatment. evaluating the severity of each compromise is essential. the decision to champion hydroxychloroquine so hastily raises yet more questions on the decisionmaking approaches, which currently show considerable disparity. several recent clinical studies have investigated hydroxychloroquine for covid-19 patients but these have been at high risk of bias, hence the need for large randomised placebo-controlled clinical trials to determine the potential benefits and harms before any role can be recommended. this story highlights the importance of an evidence-based approach that we increasingly recognise in the practice of dentistry. j sir, readers will be aware of the autoimmune disease systemic lupus erythematosus (sle), owing to the associated oral, head and neck manifestations. the efficacy of hydroxychloroquine in reducing the risk of severe lupus flares is well documented. given that the emergence of a suitable vaccine against the 2019 coronavirus disease (covid-19) may be a seemingly distant prospect, several clinical trials are underway to evaluate a potential role for existing drugs. hydroxychloroquine is one such drug with hypothesised mechanisms of action and in vitro evidence supporting the inhibition of severe acute respiratory syndrome coronavirus 2. 1 however, in an almost desperate attempt to lessen the burden of the pandemic, physicians are sporadically prescribing the drug with little evidence informing whether they are appropriate for treating covid-19. 2 propagated in part by president trump's endorsement, the sudden demand for hydroxychloroquine has created a shortage in its availability to patients requiring this medication. 3 the impact of withdrawing the medication for just a fortnight can exacerbate flares and heighten disease activity in otherwise stable sle patients. 4 the drug is vital and unique in its ability to prevent further systemic complications and increase chance of survival. 5 the attention drawn to the covid-19 pandemic risks compromising the provision sir, antimicrobial stewardship is as important now as before the pandemic and this includes ensuring correct doses are prescribed. treating paediatric patients in an urgent dental care centre at newcastle dental hospital, we have worryingly seen a shocking proportion of children who have been prescribed age-inappropriate, suboptimal doses of antibiotics and subsequently referred for treatment as 'unresponsive to antibiotics' . it is perhaps unsurprising to note a lack of clinical improvement in these cases. paediatric doses for amoxicillin increased in 2014 and excellent guidance on antibiotic prescribing is available from multiple organisations such as fgdp 1 and sdcep. 2 we simply wish to highlight that any child over five years of age should be prescribed an 'adult' 500 mg dose sir, as a british army dental officer i was taught the 7ps: prior planning and preparation prevents piss poor performance. being more polite, the united states air force changed the fifth p to 'pitifully' . 1 this is a shame as the surprise and fun of the mild expletive makes the adage memorable. later versions sometimes substituted 'practice' for the third p. we were also taught to be 'joined up' . the faculty of general dental practice (fgdp) produced a comprehensive list of guidance, news and resources for general dental practice in the covid-19 era. 2 not surprisingly, there are inconsistencies and differing viewpoints, both within dentistry and with our medical and nursing colleagues about the new normal, particularly concerning aerosol generating procedures (agps). these are critical to modern dentistry, but are not unique to us. it has been noted anaesthetists consider working in the upper airway to be an agp but dentistry is not mentioned. 3 the latest cochrane commentary on personal protective equipment (ppe) for general dental practice states 'none of the 24 identified studies... was based in the dental environment or included members of the dental team' . 4 the centre for evidence based medicine's commentary on ppe in primary care concerns general medical practice. it introduces a new term of aerosol generating exposures (age) to include agps and additional risks like patients coughing. also, requiring gold plated evidence may be the enemy of good policy. we need to look at all evidence, both observational and experimental. 5 following the severe acute respiratory syndrome (sars) outbreak 2002-2004, ppe for dental procedures was proposed. 6 it did not discuss wider implications, such as  810 british dental journal | volume 228 no. 11 | june 12 2020 upfront in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) covid-19: us gives emergency approval to hydroxychloroquine despite lack of evidence regulators split on antimalarials for covid-19 a randomized study of the effect of withdrawing hydroxychloroquine sulfate in systemic lupus erythematosus effect of hydroxychloroquine on the survival of patients with systemic lupus erythematosus: data from lumina, a multiethnic us cohort (lumina l) key: cord-270712-v6nnnzhm authors: woodcock, j. a. title: test, test, test! date: 2020-06-26 journal: br dent j doi: 10.1038/s41415-020-1800-7 sha: doc_id: 270712 cord_uid: v6nnnzhm nan patients' general medical practitioners (gmps), funding restraints have resulted in nhs clinical commissioners advising against the routine prescription of high fluoride toothpaste in primary medical settings. 2 we conducted a pilot survey investigating the awareness of orn amongst gmps and gmp trainees in the midlands in 2019, the results demonstrating that this was very limited, but that there was a willingness to engage in teaching and education. the potential role for gmps to support with preventative measures and vulnerable patients struggling to access routine dental care was identified. while dentists can continue support for these patients, future education and collaboration with our medical colleagues in primary care must also be considered in order to improve patient access, and ensure holistic patient care is being provided across all clinical settings. s. lakhani, k. martin, birmingham, uk sir, i was disappointed to read the statement in an otherwise excellent document from the fgdp and college of general dentistry that pre-treatment antiviral mouthwash was not recommended because of 'a lack of evidence of virucidal activity for use of pre-operative mouthwash'. i wonder if a flurry of recent papers, possibly overlooked, might lead to a questioning of that statement. what is now known is that sars-cov-2 replicates in the oral cavity and that extremely high numbers (>10 million) of infectious viral particles per ml saliva can be found at an early stage in sars-cov-2 infection. 1 the virus in saliva is not contamination from elsewhere, but reflects active replication probably in ace2 positive epithelial cells in minor salivary glands. 2 similar high levels are found in the nose. 3 this is clearly an infection risk to any clinician working around the mouth or nose. any virucidal agent applied to those sites may substantially reduce the risk of cross infection. 4 several commonly used antiseptic mouthwashes with anti-bacterial activity also have anti-viral activity against coronaviruses demonstrated in vitro. 5 two (povidone iodine and ethanol) have been shown to have substantial activity against sars-cov-2 and one (pvp-i) sars-cov in the presence of organic matter designed to replicate in vivo conditions. 6 what is not known is how effective any anti-viral mouthwash actually is in vivo, nor how long the antiviral effect lasts. this has been estimated as greater than 20 minutes. 4 thus, does one recommend withholding a potentially effective agent (thus potentially exposing substantial numbers of dental hcws to extra risk), or does one recommend that a simple, cheap, safe and potentially effective agent is used to help safeguard the profession while the extra information is sought? pvp-i has been used in dentistry for over 60 years and its safety profile well sir, each year there are approximately 12,200 new cases of head and neck cancer diagnosed in the uk. 1 for patients undergoing radiotherapy (either alone or in conjunction with resective surgery), the detrimental effects on oral health are well established, including the risk of developing osteoradionecrosis (orn) of the jaws. preventative advice is paramount to reduce the need for future 'high risk' procedures including exodontia, which could initiate orn. clinical guidelines on the oral management of oncology patients recommend that adults are prescribed 5,000 ppm fluoride toothpaste and to rinse at least once daily with an alcohol free fluoride mouthrinse (0.05%). however in reality, this is not always the case. for oncology patients without a regular gdp, or those who may have intermittent treatment in a tertiary dental centre, accessing prescriptions for high fluoride products may be particularly challenging during covid-19. although fluoridated products could be prescribed by sir, there are two reasons why the current guidelines pose an existential risk to dental practice: • the additional costs involved plus the required fallow periods make general practice dentistry unsustainable • the necessity to approach our patients while dressed like darth vader will raise perceived levels of fear and panic among them. many will think that our practices are 'hot beds' of covid-19 infection and they will simply stay away. the policy as it stands (both in terms of national control and the dental protocols) will simply allow us to lurch falteringly to the inevitable second lockdown, due in the autumn or winter. the only way forward is to take charge of our own profession and use our own applied knowledge and skills. there   is a workable alternative approach and it relies on two fundamental factors: • in dental practice the vast majority of dental patients are booked as 'elective' patients. we know who they are, we know when they are coming and we know what we are planning to do for them when they arrive. this means we can plan in advance of treatment and we can choose to delay treatment if necessary. medical personnel in icus at hospitals have to be in close proximity to infectious patients -we do not have to be, nor should we be • the only patients who present any form of risk from dental treatment (agps included) are those patients who are actively infectious at the time of treatment. someone who has not been infected by the virus poses zero risk and someone who has been infected but recovered and seroconverted poses zero risk. only a very small percentage of the population are infectious at any one time and these individuals are infectious only for a limited time. the smart strategy means we need to identify the risk patients by advance swab testing of our patients when they require an appointment. swab testing could be done onsite by a trained practice member in advance of any appointment booking. those who test negative would be allowed normal full access to dental services. these appointments would be undertaken using exactly the same protocols as were used prior to the covid-19 outbreak. those who test positive will need to delay booking until they have a negative test -presumably about four weeks later if they remain well. the main advantage of this approach is that it is proportional, specific and minimally disruptive. furthermore, if the dental profession begins to test all of our patients this will have a significant advantage for the population as a whole, taking a burden away from the government or other healthcare sectors. therefore, we do not need to change dentistry fundamentally forever, we need to be smart and targeted for now. if testing is done by the dental profession there will be spin-off benefits for all. to use the current 'management speak' it is a win/win situation. https://doi.org/10.1038/s41415-020-1800-7 sir, while going through a large pile of past copies of the bdj, a front cover image is shown of a 'face-mask for the protection of the dentist while operating' circa 1920, 100 years ago (fig. 1) . it is important to reflect that we have always been an infection aware profession and have therefore often been at the forefront of infection control in the surgery for both our patients and the whole dental team. 1 along with other dental schools, 2 we stopped student patient contact before lockdown, however, we have continued with online lectures, tutorials, one to ones and imaginative online remote assessment. we are now grappling with the expectation of teaching again in september. naturally, much important education can occur for example, with group work on evidence-based dentistry and with teaching preclinical skills in skills laboratories. indeed, some elements of education, such as case reports, clinical reasoning and team care planning are probably easier to timetable across year groups and inter-professionally in the virtual environment, than face to face. as primarily a school teaching dental nurses to certificate level, separate degree programmes in dental therapy and in dental hygiene, as well as teaching final year students from king's college london integrated team care, our focus on minimal intervention comes to the fore in a post covid-19 era. however, even behind our ffp3 masks and visors, the logistics of teaching clinical skills and caring for patients will remain a significant but critical challenge in our large open clinics with narrow passageways between clinical units. in addition, the need for one to one qualified dental nursing and new equipment that produces less aerosol, will not just need imagination, but like all of high street dentistry, considerable financial investment. we are about to enter a new era of dental education. d. r. radford, c. louca, portsmouth, uk https://doi.org/10.1038/s41415-020-1801-6 sir, we would like to highlight a case of oral squamous cell carcinoma (oscc) brought to our attention via digital and virtual communications methods. a 78-year-old male, in the midst of the recent pandemic lockdown, could not access an in-person consultation at his local gp surgery. his son was able to arrange tele-communications with the gp using a smartphone to take photos at the patient's home and email them to the gp who, after review, forwarded these via email to our oral and maxillofacial surgery department for assistance (fig. 1) . on receiving the photos an immediate video consultation was set up between clinician, patient and family member using nhs attend anywhere to allow an initial history and assessment to be undertaken. it was suspected that the lesion was sinister and further higher quality photographs were requested and received reinforcing concern of an advanced lower lip scc. urgent head and neck scans and biopsy investigations were organised for a one-time hospital visit, to reduce the number of in-person interactions for this shielded patient. by this stage a primary care assessment, secondary care referral, subsequent history and examination and planning of one-day further investigations   fig. 1 the cover image of the bdj volume 227 issue 8, published on 25 october 2019 conditions for which over the counter items should not routinely be prescribed in primary care: guidance for ccgs systematic review of adherence to infection control guidelines in dentistry dentistry and coronavirus (covid-19) -moral decision-making key: cord-029722-85h5060v authors: proffitt, edmund title: decoding the english standard operating procedures for dentists and the dental industry date: 2020-07-24 journal: br dent j doi: 10.1038/s41415-020-1853-7 sha: doc_id: 29722 cord_uid: 85h5060v the recently published standard operating procedure: transition to recovery for the resumption of dental treatment in england may prove to be not only the blueprint for the resumption of face-to-face treatments, but also a possible catalyst for change. seemingly, the raison d'être of the new standard operating procedures is not just to outline the detailed procedures for kick-starting dentistry, but also to support practices through transition and the shift towards a preventative and minimally invasive clinical approach that meets the current clinical challenges, and possibly then goes beyond. detailed guidance is also provided throughout the document, including the provision and type of required personal protective equipment and clinical guidelines. it may, however, prove to be not only the blueprint for the resumption of face-to-face treatments, but also a catalyst for change as cdo england, sara hurley, outlined in her introduction to the document: 'the limitations in agps present an opportunity to re-think our approach to care pathways. the patient-focused, team-delivered minimum intervention oral healthcare philosophy helps in taking on the current challenges in delivering dental care. the philosophy with its four interlinking domains of identifying the problem, prevention & control, minimally invasive treatments and suitable recall strategies dependent upon longitudinal disease susceptibility, underpins all disciplines of dentistry. whilst dental teams may use a variety of acceptable techniques to risk manage care, the guidelines for remote consultations, non-agp periodontal treatment, restorative and paediatric dental care contained in this sop provide an aide memoire to best practice, minimising agps and delivering quality health outcomes' . 2 seemingly, the raison d'être of the new sops is not just to outline the principles and procedures for kick-starting dentistry, but also to support practices through transition and the shift towards a preventative and minimally invasive clinical approach that meets the current clinical challenges, and then goes beyond. it could be seen as a vehicle to herald what the cdo england has described as a 'covid-19 legacy hallmarked by a determined revision of the current activitydriven clinical approach, optimising time with patients and delivered as an integrated oral health team.' 3 beyond the scope of the sop document, there also appears to be an appetite for contract reform to support this 'revision' going forwards. the document anticipates and paints a picture of a phased approach to full resumption based on risk management and outlines the steps in some detail, with those steps thoroughly dependent upon risk assessment and the availability of ppe at all stages. from an industry perspective, the british dental industry association (bdia), supported by its members, has worked hand in hand with the office of the cdo (ocdo) england, the bda and many other professional organisations, government agencies and representative parties every step of the way towards resumption, and standard operating procedures for dental practices to undertake a phased transition towards the resumption of a full range of dental provision in england have now been published by the nhs/office of chief dental officer england. the document essentially fulfils the role of a 'resumption blueprint' for dentistry in england and could also be seen as a catalyst for change in how dentistry is delivered going forwards through the covid-19 pandemic and beyond. resumption of treatment will be risk-assessed throughout and will bring a number of very significant changes in the way in which dentistry will be delivered, with a heavy emphasis on personal protective equipment and strict infection prevention and control. the recently published standard operating procedure: transition to recovery for the resumption of dental treatment in england may prove to be not only the blueprint for the resumption of face-to-face treatments, but also a possible catalyst for change. seemingly, the raison d'être of the new standard operating procedures is not just to outline the detailed procedures for kick-starting dentistry, but also to support practices through transition and the shift towards a preventative and minimally invasive clinical approach that meets the current clinical challenges, and possibly then goes beyond. detailed guidance is also provided throughout the document, including the provision and type of required personal protective equipment and clinical guidelines. has advised on ppe and product availability regularly. in the short term, ppe provision remains a challenge for the dental (and broader medical) devices supply chain, both in terms of availability and cost. however, things do seem to be easing gently as time moves on, but we cannot completely eliminate the possibility of some further future supply chain 'wobbles' , and should anticipate and prepare for contingencies as the profession and industry move forwards together along the road to resumption. we must not, of course, disregard the possible impact of the end of the brexit 'transition period' as the uk currently remains set to leave the eu on 31 december 2020. however, perhaps we can take heart in some words from the cdo england, who wrote: 'i strongly argue that dental care has not run out of road and that covid-19 presents the opportunity to shift gear and change lanes' . 3 moving forwards, with an initial helping hand of ppe from the department of health and social care, the industry is confident that dentistry's highly professional supply chain can fully support the accelerating pace of resumption. however, at this point in time, both the profession and industry cannot predict what the rate of recovery and treatment volumes will be, or whether there may be additional lockdowns or cessations of treatment based on future disease patterns. with the need for additional ppe and aerosol generating procedure (agp) mitigation activities, patient throughput remains a challenge. this will inevitably have implications for income generation and the sustainability of both dental practices and the dental industry. anecdotal estimates of around 30-40% of historic patient activity resuming over the coming months will mean that practices and the industry will face some significant economic challenges along the 'road to resumption' . moving back to ppe, the sops do contain much technical detail of interest and relevance to all of us. its protocols remain fully in line with government advice and public health england (phe) remains the final word on ppe. the sops contain no real surprises in this area but are helpful in terms of detailing requirements. incidentally, the document lists what constitutes both agp and non-agp activities in its 'section 3' . for non-agp care, standard infection control precaution ppe consisting of eye protection, disposable fluid-resistant (type iir) surgical masks, disposable aprons and gloves are cited. for all agps, to prevent aerosol transmission, disposable fluid-repellent gowns (or approved equivalent), gloves, eye/face protection and an ffp3 respirator should be worn by those undertaking or assisting in the procedure. however, it is important to note that the sops do allow for a fit-tested ffp2 respirator to be used where ffp3s are not available. in the real world of current global ppe supply, this means that the much more readily available ffp2 respirators will be the backbone of the resumption of any agp-based activity going forwards. subsequent to the publication of standard operating procedure: transition to recovery, on 9 june 2020, nhs england issued updated guidance for healthcare providers, including dental practices, aimed at minimising nosocomial infections in the nhs. 4 the guidance states that, from 15 june 2020, all staff in dental practices will be required to wear a surgical face mask when not in ppe or in a part of the facility that is covid-secure. phe has also responded to requests from the industry and has provided the bdia with a detailed interpretation of covid-19 guidance for dental industry maintenance, and service engineers and technical staff attending dental practices, so that surgeries can rest safe in the knowledge that the industry has its own bespoke phe guidance on appropriate ppe to wear when visiting practices. the sop document also clarifies sessional use of ppe, stating that fluid-resistant (type iir) surgical masks and eye protection can be used for a session of work rather than a single patient or resident contact. it also confirms that ffp2/n95 respirators are suitable for sessional use in dental practice, adding that a full-face visor changed between patients will protect the respirator from droplet/ splatter contamination. the procedures also state that, although good practice, there is no evidence to show that discarding disposable respirators, face masks or eye protection inbetween each patient reduces the risk of infection transmission to the health worker or the patient. among the procedures, guidance, illustrations, tables and appendices featured, there are, of course, some central and fundamental tenants and core guidance which are becoming part of the covid-19 era's dental mantra. where dental treatment is planned, care planning should focus on achieving stabilisation, intervention should be kept to a minimum to reduce exposure risk, and agps should be avoided where possible and only undertaken if the dental service has the appropriate ppe. treatment should be completed in the minimum number of visits possible, and when an agp has been undertaken, it is recommended that the room is left vacant for one hour for a neutral pressure room before cleaning is carried out. this period did raise a number of eyebrows and there are differing times cited in guidance from other countries. 5 it is understood that additional mitigation means and technologies could play a part in reducing this time, subject to suitable risk assessment. of course, patient flow and practice layout should be considered in order to comply with social distancing measures throughout the practice, with reception use minimised, digital appointment booking (online, e-mail) used, the consideration of fitting physical barriers at reception (for example, perspex shields) and arrangements for contactless card payment where possible. the dental industry will endeavour to render all possible help and support to practices through all of these steps. additional training of staff may be necessary and should be provided before recommencing any dental provision. areas highlighted include rubber dam placement, four-handed techniques, decontamination and ipc, remote consultation and triaging, training in new it software tools (for example, online medical history software), and scenario-based team training of new policies and procedures. again, the dental industry will endeavour to render all possible help and support to practices through all of these steps and processes. as services resume and practice capacity to provide care hopefully accelerates and increases, there will be a demand for a broader range of clinical activities and thus support from the industry. areas of support to the profession will include tools to assist in preventative and self-care measures, delivered in line with delivering better oral health, 6 and in agp mitigation. the sop document highlights and addresses areas of agp mitigation, including the use of hand instrumentation/ scaling and non-agp periodontal treatment, simple dental extractions, caries excavation with hand instruments, caries removal with slow-speed and high-volume suction, the placement of restorative material, orthodontic treatments and paediatric oral health, including stainless steel crowns and diamine fluoride applications. detailed appendices provide guidance in these areas. by working through the sops, the dental industry can identify just how and where it can support the resumption of more widespread dental treatment in the community and, importantly, explore new opportunities and areas of support for practices and the profession going forwards, as dentistry takes this opportunity to re-think and re-evaluate its approach to care pathways. resumption is a partnership between many groups: the patient, the dental team, the dental industry, the nhs, the bda and other professional bodies and organisations, regulators and the government (apologies to any others that i have missed out). while there are a plethora of ideas and views across these groups, the most important thing is that they share common goals. why re-invent the wheel you've out of road? minimising nosocomial infections in the nhs recommendations for the re-opening of dental services: a rapid review of international sources -version 1.1. 2020. available online at https:// oralhealth.cochrane.org/news/recommendations-reopening-dental-services-rapid-review-internationalsources delivering better oral health: an evidence-based toolkit for prevention key: cord-307144-g8d1xkub authors: monaghan, n. p. title: emerging infections – implications for dental care date: 2016-07-08 journal: br dent j doi: 10.1038/sj.bdj.2016.486 sha: doc_id: 307144 cord_uid: g8d1xkub over the last 20 years the majority of emerging infections which have spread rapidly across the globe have been respiratory infections that are spread via droplets, a trend which is likely to continue. aerosol spray generation in the dental surgery has the potential to spread such infections to staff or other patients. although the diseases may differ, some common approaches can reduce the risk of transmission. dental professionals should be aware of areas affected by emerging infections, the incubation period and the recent travel history of patients. elective dental care for those returning from areas affected by emerging infections should be delayed until the incubation period for the infection is over. if dental teams are aware of these issues they can reduce the risks to them and their patients. dentistry is often forgotten when new infections emerge; the appointment of dental emerging infection leads could ensure prompt advice is available. emerging infections -implications for dental care n. p. monaghan 1 countries, toronto, spain and the uk. 2 sars was caused by the sars cov virus, a coronavirus related to some of the viruses associated with common colds. there were 747 deaths among 9,098 reported cases. half of those over 65 who were known to have been infected died. currently there is ongoing surveillance about a different coronavirus -mers cov, which originated in the middle east. this new infection is now suspected to have originated from a single animal source, a camel, in 2011 or earlier. 3, 4 mers cov was first reported in 2012 and by july 2015 had been reported in 21 countries. while most cases have involved people from or visiting saudi arabia, there is an ongoing outbreak in the republic of korea. 5 between 2003 and 2008 it was predicted that a new form of influenza might emerge to affect humans. 6 birds in south east asia were expected to be the source. there are many strains of influenza viruses and many host species. birds, dogs, horses, pigs, humans and many other species of mammals can be affected by influenza a viruses. 7 in 2009 when a new influenza pandemic did occur it started through contact with pigs in mexico. the virus was h1n1, similar to the strain involved in the 1918 'spanish' influenza pandemic which killed about 50 million people and to the 1977/78 'russian' flu virus. 8 ebola has been known about since 1976. 9 the outbreak in west africa which commenced in december 2013 has led to cases being managed an infectious disease is regarded as emerging when the number of humans contracting an infection has increased in the past 20 years, or when there is threat of such increase in the near future. 1 there are different reasons why a disease may emerge including: • new infections from changes or evolution of existing organisms • infections affecting new areas (for example, possibly associated with ecological changes such as global warming) • old infections re-emerging because of poor public health measures or the development of antimicrobial resistance. infectious diseases that are transferred easily from person to person have scope for rapid spread. airline travel in particular can contribute to rapid spread across the globe. in 2002 a new infection emerged, severe acute respiratory syndrome (sars), initially in china but rapidly spread via international travellers to other asian over the last 20 years the majority of emerging infections which have spread rapidly across the globe have been respiratory infections that are spread via droplets, a trend which is likely to continue. aerosol spray generation in the dental surgery has the potential to spread such infections to staff or other patients. although the diseases may differ, some common approaches can reduce the risk of transmission. dental professionals should be aware of areas affected by emerging infections, the incubation period and the recent travel history of patients. elective dental care for those returning from areas affected by emerging infections should be delayed until the incubation period for the infection is over. in the usa, italy, the uk and spain. as of 20 january 2016 there have been 28,602 known cases associated with 11,301 deaths. 10 by august 2014 there had been 1,000 deaths in west africa and a british volunteer nurse had contracted the disease and been flown back to the uk for emergency treatment. 11 within the uk guidance was issued to dental teams in england (december 2014), wales (december 2014), northern ireland (january 2015) and scotland (february 2015). [12] [13] [14] [15] the emerging infection which hit the news in january 2016 is zika virus. this virus is carried by mosquito species such as aedes aegypti, which also carries yellow fever and dengue viruses. zika virus was first discovered in uganda in 1947 and since has slowly spread through south asia and pacific islands to reach brazil. 16 currently there are concerns about possible links with microcephaly. a known rare complication of zika infection is guillain barré syndrome. currently, zika infection risk in the uk would be limited to imported cases of people infected abroad, reflecting the locations where mosquitoes are carrying zika virus. aedes aegypti is currently restricted to presence in madeira, georgia and south russia, although it was recently found for the first time in the netherlands. 17 in none of these areas has zika virus been reported to date. 18 the emerging infections noted above are those which have hit the uk media. there are many other emerging infections. tb is opinion re-emerging in some areas, particularly london where it accounts for 40% of all uk cases. 19 given features of the infections which have emerged (or been expected to emerge) over the last 20 years and have potential to spread rapidly and cause significant loss of life, what is the relevance to dentistry? among the diseases which have emerged two are coronaviruses, one an influenza virus. coronaviruses and influenza viruses are spread via droplets, aerosols, or through direct contact with respiratory secretions of someone with the infection. the virus particles can survive within small droplets in the air for several hours. 20 thus when influenza is circulating there is a potential higher risk of transmission within dental practices because of the aerosol sprays generated by drills and ultrasonic scalers. for influenza it is thought that this risk of transmission is restricted to the room where dental care is given, provided the door to the room is closed. 21, 22 in the early phase of response to h1n1, when there were concerns that this form of influenza caused high mortality, the american guidance recommended negative pressure air handling and full fit-tested protective equipment. 23 in recent years a large proportion of the emerging infections have been viral infections of the respiratory tract, spread through droplets and aerosols. these have the potential to pass from person to person, and even country to country, very quickly. dental practice, involving both close contact to the airway and generation of aerosol sprays, presents a high-risk environment to catch or pass on these infections. 24 however this risk can be reduced by use of masks and gloves, pre-procedure rinses, rubber dam and high volume suction. 24 while not a 'digestive tract infection' , ebola is an infection which can be transmitted from body fluids including those affecting the digestive tract. the virus can survive for several days outside the body and a person can become infected via the mouth. 25 it is common for people to be advised not to kiss those who are symptomatic with gastrointestinal infection. although ebola virus is not believed to commonly spread as a result of droplet generation, contact with mucous membranes of an affected person is a mechanism for transmission of the virus. aerosol sprays bombardment of mucous membranes of someone with the disease is a potential mechanism to facilitate transmission of ebola (or a digestive system infection) when the causative organism may be present in the mouth of those infected. viruses are present in saliva of those very sick with ebola. droplet transmission of ebola from aerosol spray has not been demonstrated to date, although there is a report of a healthcare worker inadvertently rubbing her eyes with soiled gloves who then developed ebola disease. 26 based on the limited evidence it would seem best to avoid aerosol spray generation from the mouth of someone with the disease. by contrast zika is spread by mosquito bites. provided that normal precautions against blood-borne viruses are used there would seem to be no reason to suppose that dental care is a risk for transmission of the zika virus. with appropriate knowledge it is possible to reduce the risk of transmission of emerging infections in dental settings. the key principles in managing someone who may have been in contact with an emerging infection are: establishing whether contact with someone affected is possible, delaying non-urgent care until incubation periods are over, and use of appropriate precautions to provide care which cannot be delayed. the implications for the dental team include: • being aware of emerging infections • being aware of incubation periods • being aware of patients' recent travel history • delaying elective treatment of those from (or returning from) affected areas who may have been in contact with cases until the incubation period has passed to reduce risk of transmission • for urgent treatment of those who may have the disease or may have been in recent contact with cases, seeking advice from health protection colleagues before providing care and use of full protective equipment. while new diseases do not emerge to become a problem every year, when they do emerge and are reported on the news it would be sensible for members of the dental team to find out a little more about the infection. key information includes whether a new infection affects the respiratory or digestive tracts, awareness of affected geographical areas, awareness of incubation periods and any advice issued by health protection experts and government health departments. avoiding provision of elective dental treatment to those who may have been exposed to the disease is a key response. for many emerging infections there will be an incubation period. elective treatment can be delayed until after the incubation period has ended. similarly if a person survives an infection, is free of symptoms and shown to be free of the causative organism, elective care can be provided. not all dental care is routine and sometimes interventional treatment is needed urgently. if urgent dental care is required for symptomatic returnees or for those who have had contact with symptomatic individuals, advice should be sought from a health protection team before treatment commences. personal protective equipment and modification of cross infection precautions will be needed appropriate to the mode of transmission of the organism. 27 decontamination of the surgery and equipment will also be needed. the surgery is more likely to become widely contaminated through aerosol sprays, therefore aerosol spray generation should be minimised. experience with sars highlights appropriate responses for a highly infectious high mortality respiratory infection. 28, 29 in the absence of negative pressure operating rooms there are products which can help to manage the air in an aerosol generating environment. 30 past experience suggests that the dental team can be forgotten when new infections emerge. if we are alert and are clear about the information we need, we can ask for up to date answers and modify our practice accordingly. public health organisations should consider appointing someone with responsibility for emerging infections and dentistry with strong links to both health protection colleagues responsible for emerging infection responses and dental professionals. their role would ensure that dental care is not forgotten when new infections emerge and that early appropriate advice is available to dental professionals. predicting the future is an uncertain business. we cannot predict accurately when the next emerging infection will arise and what it will be, but we can identify features of such diseases with implications for dentistry. recent experience suggests that most emerging infections with potential to spread rapidly across the globe and cause significant loss of life will affect the respiratory tract. dental professionals should be aware of (and be made aware of) such infections because they have potential to be spread by generation of aerosol sprays in the oral cavity. awareness of emerging infections and of patient travel histories can assist us in reducing the risk of transmission of emerging infections in dental settings. if we strengthen links with health protection colleagues responsible for emerging infection responses we will be well placed to keep dental professionals informed. emerging infectious diseases sars (severe acute respiratory syndrome) molecular epidemiology of human coronavirus oc43 reveals evolution of different genotypes over time and recent emergence of a novel genotype due to natural recombination full-genome deep sequencing and phylogenetic analysis of novel human betacoronavirus middle east respiratory syndrome coronavirus (mers-cov) directorate-general for health and consumer protection european commission. factsheet -avian influenza evolution and ecology of influenza a viruses influenza: the mother of all pandemics world health organization. ebola haemorrhagic fever in sudan british ebola patient arrives in uk for hospital treatment ebola guidance for dental care teams ebola dental guidance wales ebola guidance for dental care teams northern ireland ebola guidance for dental care teams zika virus: a previously slow pandemic spreads rapidly through the americas european centre for disease prevention and control. aedes aegypti european centre for disease prevention and control. epidemiological update: outbreaks of zika virus and complications potentially linked to the zika virus infection the white plague returns to london with a vengeance concentrations and size distributions of airborne influenza a viruses measured indoors at a health centre, a day-care centre and on aeroplanes prevention of 2009 h1n1 influenza transmission in dental health care settings pandemic (h1n1) 2009 iinfluenza a summary of guidance for infection control in healthcare settings prevention of swine influenza a (h1n1) in the dental healthcare setting aerosols and splatter in dentistry: a brief review of the literature and infection control implications ebola virus disease -how it spreads review of humantohuman transmission of ebola virus standard and transmission-based precautions -an update for dentistry severe acute respiratory syndrome (sars) and the gdp. part i: epidemiology, virology, pathology and general health issues severe acute respiratory syndrome (sars) and the gdp. part ii: implications for gdps a pilot study of bioaerosol reduction using an air cleaning system during dental procedures key: cord-273335-ogxq6vtc authors: banerjee, avijit title: minimum intervention oral healthcare delivery is there consensus? date: 2020-10-09 journal: br dent j doi: 10.1038/s41415-020-2235-x sha: doc_id: 273335 cord_uid: ogxq6vtc nan f irstly, i' d like to take this opportunity to offer all bdj readers my sincere best wishes in what has been a trying 2020 so far. at the beginning of a new decade, heralded by many as a fresh chance for humanity to embrace and nurture all that is positive in global and local society, we find ourselves having to re-adjust radically, both personally and professionally in such unusual times, to a new 'norm' and there is still much to evolve in this regard. i have purposely avoided the over-used descriptor, 'unprecedented' to describe the events that have transpired. pandemics are not unprecedented. indeed, they have and continue to affect humankind with a certain biological regularity over history. what is unprecedented is the reaction of humankind. as society has begun the complex reactionary re-adjustment, it is clear that in the healthcare sector, many work practices and tenets of care delivery will be forced to change. positive opportunities need to be taken by all stakeholders in dentistry involved in delivering the best oral healthcare management to patients. these stakeholders include the clinical/research profession, educators, the needs, wants and expectations of the public/ patients, industry partners, service providers, indemnity associations and service regulators. therefore, this second minimum intervention (mi)-themed issue is in my opinion, quite timely in its planning, production and release. mi association with the bdj began in early 2012. an informative series of mi-related papers in conservative dentistry had been published in a french journal, réalités cliniques, the previous year. i felt compelled to speak to my dear friend, colleague and bdj editor-in-chief, stephen hancocks to see if these could be adapted and reprinted in the bdj, so increasing their exposure to a wider audience. he agreed and hey presto, in 2012 and 2013 in bdj volumes 213 and 214, they were published and proved to be of real interest and inspiration to the readership. suitably enthused, in 2013, stephen then kindly invited me to author an editorial opinion piece introducing and outlining the concept of prevention-based minimumintervention oral care (mioc) provision and the challenges it might face in gaining acceptance in the mainstream profession. 1 the mioc team-delivery framework is based around four interlinked domains, applicable to any of the restorative disciplines, across all ages and patient groups (with suitable adaptions where necessary) ( figure 1 four years later, i was again delighted and honoured this time to coordinate, co-author and present the first mi-themed bdj issue as its guest editor, commissioning a selection of high quality manuscripts from national and international renowned professionals and dear colleagues with an acknowledged expertise in mi dentistry. 2 as can be seen from the range of papers published in that issue, alongside many other important publications in the dental literature, the clinical academic evidence for mi dentistry is now far-reaching and more widely accepted as to be considered a mainstream approach in the profession and not solely for caries management as many still perceive. the advances in clinical operative techniques/ technologies/materials, behaviour management and another form of mi, motivational interviewing, are all enabling oral healthcare teams to deliver successfully this contemporary approach to achieve and maintain oral health and long term wellbeing in our patients. 3, 4, 5, 6 however, even with such evidence laid bare, it is clear that the uptake of minimally invasive operative principles/approaches, for example in caries management, is not universal in primary care practice. 7 ' through such adversity comes the glimmer of opportunity to change and develop new strategies and mechanisms to deliver better oral health programmes' that in 2020 this second mi-themed issue has been published, collating international experts' outputs on how the accepted principles of mioc/minimally invasive operative dentistry (mid) can be implemented in the broader world of 'real-life' primary care dentistry, for the benefit of our patients long term. this issue, which should be read and digested in conjunction with the contents of the first mi-themed issue, focuses on clinical implementation strategies across the various disciplines of clinical dentistry that primary care practitioners and their teams experience on a daily basis. one year ago, i gave the authors the brief to summarise knowledge and offer potential solutions/guidance for the use of mioc principles to manage day-to-day patients seen in a non-specialist, primary care setting. the clinical disciplines covered in this issue include, in no particular order, orthodontics, cariology (including detection technologies, an update of restorative biomaterials and consensus guidelines of when to intervene in the caries process), periodontology, prosthodontics, paediatrics and the mi restorative management of the anxious/phobic patient. the implementation challenges of mioc across the world are discussed, using the us as a specific example. it is clear from these insightful papers that the underlying tenet of patient-focused, oral healthcare team-delivery is applicable to all patients, at all stages of their lives, whether disease-active or in health. indeed, the underpinning strength of the mioc framework domains is the continuity of care with underlying team-delivered communications to patients, to value and take responsibility of their own general and oral health. this message has never been as pertinent and meaningful as it is now. 9 dental caries is still one of the most prevalent non-communicable diseases affecting humankind globally. 10 there is clear need and benefit to have guidance as to how to deliver mioc and mid to individuals, local regions and country-specific populations. of course, as all clinicians appreciate, there is always variation between practitioners as to how to resolve particular clinical challenges, with many, often subjective, factors to be taken into account. to help in such instances, it is useful to have guidelines/standard operating protocols (sops) to help oral healthcare teams to manage their patients. these cannot be restrictive rules and regulations; they should be a learned summation of the current, collated expert consensus, scientific and clinical evidence, however strong or weak these may be, to be considered along with the individual patient, practitioner and local factors pertaining to each clinical scenario/patient and adapted accordingly. 11 in this way, each patient receives optimal care and the team/practitioner can feel confident in their approach and can also learn from others/add to their clinical experience and acumen, collectively. the implementation of such consensus guidelines needs to be accompanied with careful communication and documentation between the team and patient of decisions made and the reasons as to why. so, where are mi guidelines? what evidence, if any, should be considered, accepted or discarded? 11 which stakeholders are responsible for generating and updating them? how can guidelines be validated locally, regionally, nationally or globally? should there be nationwide/global coordination/training? there are many important guideline publications available for each of the different disciplines in restorative dentistry, including periodontology, prosthodontics and endodontics. these often concentrate on standardising specific operative treatment protocols for more clearly defined clinical situations. these are published by expert panels representing learned societies, royal colleges and government bodies. these groups are sometimes assisted by industry partners to help convene the discussions. it is important, however, that industry partners do not influence the outcomes and these are kept strictly independent to avoid inappropriate bias. the discipline of conservative & mi dentistry in primary care covers a great breadth and variety of clinical situations affecting a large, heterogeneous population. many management variables (technologies, procedures, materials, operator skills, knowledge, experience and a multitude of patient factors including attitudes/ behaviour/socio-economic status etc) all need to be considered when attempting to develop suitable treatment guidelines to help practitioners and their teams. 12 thanks to this complex interaction of variables, there is a relative paucity of clear-cut, high quality evidence (for example, randomised controlled clinical trials) to enable such guidance to be absolute, conclusive and applicable to all scenarios. as an example of a response to collate further high quality clinical evidence, the national institute for health research uk (nihr) is currently funding two national multi-centre primary care randomised controlled trials, one on minimally invasive operative caries management -selective caries removal in permanent teeth (script), and the other on pulpotomy for the management of irreversible pulpitis in mature teeth (pip). these studies provide an exciting opportunity for nhs primary care dentists and their teams to get involved with 'real-life' clinical trial data collection which will contribute to the evidence base to support advances in service provision (practice expenses are covered and ecpd awarded when participating in the trials direct/indirect restorations, pulpotomy/root canal therapy (endo), bridges/implants/dentures (prostho), root surface debridement, orthodontics/paediatrics (hall crowns) (1° 2° 3° care provision) specialist/dentist/therapist/ hygienist fig. 1 the mioc framework applied to the different disciplines within restorative dentistry (conservative dentistry and endodontics, periodontology, prosthodontics and orthodontics), showing the four interlinked domains and the oral healthcare team members responsible in each (eddn -extended duties dental nurse, ohe -oral health educator). minimally invasive operative dentistry forms one of the domains within the mioc framework for delivering better oral health. tsl -tooth surface loss -please email script@dundee.ac.uk / pip-study@dundee.ac.uk for further information about participation in these trials). in conservative & mi dentistry including endodontics, there are many national and international learned societies and consensus panels, all providing useful information about the terminology, prevention and management of caries, 13, 14, 15, 16, 17 toothwear 18 and management protocols for broken-down teeth. the european federation of conservative dentistry (efcd) and the european organisation for caries research (orca) have collaborated in an attempt to collate and generate pragmatic, evidence-based guidance for primary care practitioners. 19, 20, 21, 22, 23 these, along with many other published efforts, are trying to help the relevant stakeholders to manage patients, improve oral health linked to general health and increase awareness in populations of their role in valuing and taking responsibility for their personal healthcare future. 24, 25 education and training courses exist to help dentists, dental therapists and team members learn about and implement mioc (for example, the online, distance-learning master's programme in advanced minimum intervention dentistry). a further consequence of the global covid-19 pandemic is the generation of a multitude of new terminologies and abbreviations. ppe (personal protective equipment for the general public at least), udc (urgent dental care), furlough, agp (aerosol generating procedure), age (aerosol generating event), ffp2/3, bapd (british association of private dentistry), abatement, social distancing are a small selection of the professional terms now commonplace in our collective vocabulary. but what about dentistry in the the postpandemic era? as i mentioned at the beginning of this piece, few, if any, could predict the dramatic changes in global health and economic outlook over the last few months and only time will tell as to how this manifests and moulds our new norms, personally, professionally and across broader society. however, through such adversity comes the glimmer of opportunity to change and develop new strategies and mechanisms to deliver better oral health programmes for our patients. national and international regulators will have to decide the new norms for social distancing at work, personal protective equipment and suitable infection prevention and control policies. will the more limited use of aerosol-generating procedures (agps) be encouraged beyond the short-term advice already actioned? personalised preventive oral health advice via online, teledentistry delivery may, or indeed should, become a funded aspect of primary care delivery, helping to evolve the relationship between 'oral health practices' and their patients. this may in turn improve the reach and access to the more under-served parts of the population. i have been invited to assist the office of the chief dental officer in england in taking forwards the initiative to develop and coordinate such clinical strategies and protocols, using these strange times as a once-in-a-lifetime opportunity to re-shape and augment the underlying clinical philosophy, building on the mioc framework across the dental disciplines to align this model of care with the phased recovery period. this should be accompanied by revised contracts and more agile nhs commissioning while ensuring resilience of the approach through local peer support, enhanced team-delivery and training provision. government messaging to the population will need to be more balanced in this regard than ever before, where prevention, self-care, personal responsibility and awareness are given maximum priority in oral health promotion. service providers, regulators and the legal/indemnity profession will have to engage more in working together towards this common goal as opposed to the somewhat continued defensive, siloed, inward-focused attitudes that still seem to prevail in times of greatest need. the maintenance of optimal oral health, inseparable from systemic health and physical/mental wellbeing, has never been so important and at the forefront of people's minds and agendas. suffice it to say, there is a hope that all stakeholders will finally start to value aspects of their own lives as well as of those whom they represent that were once, perhaps, taken for granted. maybe, just maybe, delivering better oral health through the mioc framework may be one of those paradigm shifts for the better. 26  https://doi.org/10.1038/s41415-020-2235-x mi'opia or 20/20 vision? minimum intervention' -mi inspiring future oral healthcare? the contemporary approach to tooth preservation: minimum intervention (mi) caries management in general dental practice the contemporary practice of mid minimally invasive long term management of direct restorations: the '5rs' longevity of defective direct restorations treated by minimally invasive techniques or complete replacement in permanent teeth: a systematic review caries prevention for children in a primary care setting -a collaborative clinical audit restorative intervention thresholds and treatment decisions of general dental practitioners in london prevention and personal responsibility global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the global burden of disease study what is evidence-based medicine? cariescare practice guide: consensus on evidence into practice managing caries lesions: consensus recommendations on carious tissue removal managing caries lesions: consensus recommendations on terminology terminology of dental caries and dental caries management: consensus report of a workshop organized by orca and cariology research group of iadr contemporary operative caries management: consensus recommendations on minimally invasive caries removal european society of endodontology position statement: management of deep caries and the exposed pulp toothwear-themed issue when to intervene in the caries process? an expert delphi consensus statement how to intervene in the caries process in children? a joint orca and efcd expert delphi consensus statement how to intervene in the caries process: proximal caries in adolescents and adults -a systematic review and meta-analysis how to intervene in the caries process in adults: proximal and secondary caries? an efcd-orca-dgz expert delphi consensus statement how to intervene in the caries process in older adults? a joint orca and efcd expert delphi consensus statement secondary caries: what is it, and how can it be controlled, detected and managed? a curriculum for behaviour and oral healthcare management for dentally anxious children -recommendations from the children experiencing dental anxiety: collaboration on research and education (cedacore) why re-invent the wheel if you've run out of road? key: cord-014344-pg6is6u5 authors: nan title: updated infection prevention and control guidance published date: 2020-11-13 journal: br dent j doi: 10.1038/s41415-020-2395-8 sha: doc_id: 14344 cord_uid: pg6is6u5 nan the bda northern counties branch agm will be held online on thursday 3 december 2020 at 19:00. please ensure you register your interest in attending at www.bda.org/bse in order to receive the link to access the agm, or email branchsectionevents@bda.org. the royal college of surgeons of edinburgh (rcsed) has become the first surgical college in the uk to offer an app to its members in a bid to transform the way training and educational materials are accessed and shared. the app will be made available to the rcsed's 29,000 members around the world, giving them access to exclusive content and information on the latest developments in the surgical field. the launch coincides with the unveiling of the college's new branding, which features edinburgh castle, to reflect its long history, and a unicorn, known for its association with healing. the unicorn was also a favourite heraldic animal of james iv, who gave the college its royal charter in 1505, with the date also featuring on the logo. members will be able to use the app to join interactive webinars with worldleading surgeons, as well as to access hundreds of 3d videos of dissected human specimens via the acland anatomy service. library services and transcripts can also be requested from the college archive and libraries team through the app, to aid with revision and studying. the full schedule of college courses, exams and events are now also accessible via an in-app calendar, enabling members to click, save and secure their spot for development opportunities. professor michael griffin obe, president of the rcsed, said: 'the impact of covid-19 has really demonstrated the importance of being able to teach and learn remotely, and this app will allow us to do even more of this, connecting surgeons like never before and allowing them to share vital information and training. 'in addition to the app, we're also very happy to unveil our new logo, which i believe reflects our friendly, forwardthinking outlook as a college, while also acknowledging our roots as one of the oldest surgical colleges in the world. ' the app has been developed in conjunction with xdesign. rcsed launches app and brand refresh 580 british dental journal | volume 229 no. 9 | november 13 2020 covid-19: infection prevention and control dental appendix mitigation of aerosol generating procedures in dentistry -a rapid review key: cord-318136-2skr13gc authors: jevon, phil; shamsi, shaam title: using national early warning score (news) 2 to help manage medical emergencies in the dental practice date: 2020-09-11 journal: br dent j doi: 10.1038/s41415-020-2024-6 sha: doc_id: 318136 cord_uid: 2skr13gc if a medical emergency occurs in the dental practice, members of the dental team must be able to respond promptly, effectively and safely. fundamental to this response is knowing when it is necessary to call 999 for an ambulance and communicating effectively with the ambulance service to ensure the timely arrival of the emergency services and timely transfer to hospital. this can be helped by using the royal college of physicians' (rcp's) national early warning score (news) 2, widely used by the ambulance service and in hospitals it reliably detects deterioration in adults, triggering review, treatment and escalation of care. although news2 hasn't yet been validated for use in primary care, nhs england is encouraging its widespread use in this sector. using news2 in the dental practice will help the dental team to effectively, confidently and safely manage medical emergencies, including sepsis, should they arise. this will facilitate effective teamwork and help to ensure enhanced patient outcomes. this article provides an overview of news2, including benefits for using it in the dental practice and guidance on how to implement it. members of the dental team are expected to be able to effectively and safely manage medical emergencies in the dental practice. 1 fundamental to achieving this is recognising when patients are ill and communicating effectively with the ambulance service to ensure the timely arrival of the emergency services and timely transfer to hospital. the royal college of physicians' (rcp's) national early warning score (news) 2, 2 widely used in the healthcare setting both in the uk and abroad, reliably detects deterioration in adults, triggering review, treatment and escalation of care. 3 although news2 has yet to be validated for use in primary care (research is ongoing), nhs england is encouraging its use in this sector. 3 the aim of this article is to understand how news2 can help members of the dental team manage a medical emergency in the dental practice. news was developed in 2012 by the rcp to improve detection of, and response to, clinical deterioration in patients who are acutely ill. 2 news2, released in 2017, 2 has been endorsed by nhs england and nhs improvement for use in both the ambulance service and in acute hospitals. 3, 4 three-quarters of acute trusts and all ambulance trusts are currently using it. 3 news has standardised how acute illness is assessed and responded to and, in hospitals alone, it is estimated that close to 2,000 deaths a year will be prevented. 2 with news2, a simple scoring system is used whereby a score is allotted to each of six physiological measurements (box 1), which are commonly undertaken in healthcare settings. 3 it has been validated for use in adults (>16 years of age) but not in pregnant women or children (<16 years of age). 2, 3 the scores are calculated using the news2 observation chart (fig. 1) . a score is allocated to each of the physiological measurements (box 1); the higher the score, the more abnormal the measurement. 3 the score is aggregated and, if the patient requires supplementary oxygen, it is increased. an elevated news score doesn't provide a diagnosis, but helps to identify patients who are sick, requiring urgent clinical review following a standardised approach. 3 the news thresholds and triggers chart (fig. 2) can then prompt an appropriate response. another chart providing guidance on the recommended clinical responses to news trigger thresholds is available, particularly for use in hospital settings. the news2 observation chart (fig 1) incorporates a number of improvements made to the first news chart published in 2012, 2 including: • the familiar and systematic 'airway breathing circulation disability exposure' (abcde) approach advocated by the resuscitation council uk to assess (and treat) the acutely ill patient • a list of ranges for the boundaries of each measurement score • a specific section (spo2 scale 2) to be used when the patient has hypercapnic respiratory failure (usually copd) who has a clinically recommended oxygen saturation measurement of 88-92% • a new 'confusion' (disorientation, delirium or any new alteration to mentation) component has been incorporated into the familiar avpu assessment tool, which is now acvpu (where 'c' represents confusion). this can help to identify suspected sepsis • improved section for the administration of oxygen • the importance of considering sepsis is emphasised in patients who are known to have an infection, suspected to have an infection or are at risk of infection; in these patients, a news2 score of 5 or more is the key trigger threshold. the rcp hopes that news2 will be validated for use in primary care, assisting triage and communication of acute-illness severity to ambulance and hospital services. 2 nhs england encourages the use of news2 to assist clinical assessment in the primary care setting, as work continues to collect reliable evidence to validate its use. 3 it has shown that the use of news in the pre-hospital setting may facilitate earlier recognition of deteriorating patients, earlier involvement of senior emergency department staff and more appropriate levels of critical care. 5 unsurprisingly, very high and very low news scores are reliable indicators to identify patients who are and are not likely to deteriorate in the pre-hospital setting. 6 higher news scores have been shown to be associated with decreased time from referral to arrival for patients conveyed by ambulance, together with decreased time from arrival in hospital to doctor review. 7 a number of doctors' surgeries (west of england, liverpool and wessex) have found the use of news helpful as an adjunct to decision-making, a prompt to do a complete set of observations and an aid to communication with the rest of the healthcare pathway, including the ambulance service, regarding deteriorating patients. 3 this enables colleagues in other settings (for example, ambulance service and emergency department) to plan, prioritise and place patients safely and appropriately. in summary, what news2 offers is a prompt to encourage the reliable taking of physiological observations, an adjunct to clinical decisionmaking and a very clear, easily communicated and well-understood physiological score that the rest of the care pathway understands. 8 although news2 has not yet been validated for use in the dental practice setting, there are a number of reasons why dental practices should seriously consider introducing it as an adjunct to help them respond to a medical emergency: • news2 can provide an objective assessment of a patient's physiological state, adding to and reinforcing clinical judgement; it can help reinforce dental teams' clinical findings and flag up patients who are more likely to deteriorate when having a medical emergency in the dental practice (particularly when consecutive news2 scores display an upward trend) • the news2 observation chart (fig. 1) reinforces the abcde approach to assess (and treat) the acutely ill patient • news2 can improve the objective assessment of patients with a medical emergency such as suspected sepsis, acute asthma attack and anaphylaxis • news2 can help with communication when calling 999 for an ambulance (every ambulance service in the uk now use it) 3 because the news2 score enables the dental team to communicate vital signs data in a common language • news2 can empower the dental team to be listened to; for example, when calling 999 for an ambulance, if they have concerns about a patient 3 • the earlier a complete set of observations is done (for example, in the dental practice), the sooner a patient can be placed on a track and trigger score, enabling deterioration to be tracked and resources prioritised 9 • in the current nhs climate where 'ambulance stacking' seems to be becoming more common, every bit of non-subjective information such as a high news score can improve the triage, speed up the arrival of the paramedics and guide the urgency of transfer to the emergency department 8 • news2 can be used for communication and handover when patients are transferred to and from acute hospitals it is important to remember that news2 does not replace clinical judgement. 9 clinical judgement should always be used, even if the news2 score is normal. the dental team should escalate deteriorating patients for review whenever they are concerned, even if the news2 appears to be reassuring. a good example of this is a patient with chest pain. a patient could be having an acute coronary syndrome (heart attack) but have a normal news2 score. guidance and advice on implementing news2 are freely available on the rcp's website (www. rcp.org.uk). in addition, some basic equipment together with appropriate staff training will be required. the following equipment/resources will be required: • blood pressure monitor: at present, only dental practices that use sedation are required to have a blood pressure monitor (fig. 3) for oxygen saturation monitoring. 11 some other dental practices already have one on the premises, but for those that don't, basic affordable devices are widely available • thermometer: dental practices should already have a thermometer (fig. 4) because, according to nice guidance, the confirmation of fever in a patient with a dental abscess is one indication for prescribing antibiotics. 12 also, due to the current crisis, a thermometer would be useful even more so now, and highly indicated in recording the temperature in a patient with suspected covid-19 infection and managing our patients effectively • pulse oximeter: at present, only dental practices that use sedation are required to have a pulse oximeter (fig. 5) for oxygen saturation monitoring. 11 however, affordable fingertip pulse oximeters can be purchased and these devices are particularly useful in monitoring patients with medical emergencies such as sepsis, acute asthma attack and respiratory difficulties that can complicate covid-19 • news2 charts: freely available from the rcp's website. they are free to use, but it is not permitted to alter them and the charts need to be printed out in colour. 2 as well as having training in the use of the above devices, staff training and familiarisation with news2 will be required. the rcp provides information relating to news2 training resources on its website. the e-learning course ('standardising the assessment of acute-illness severity in the nhs') is free for nhs staff with an nhs e-mail address (nhs.net or nhs.uk). a training document together with webbased educational tools in varying formats to support news2 being implemented at local level are available at http://tfinews. ocbmedia.com. 2 these resources include using supplementary oxygen, the importance of new confusion and how news2 can be used to recognise sepsis. 2 in addition, news2 refresher/awareness training can be simply included in annual medical emergencies training undertaken in dental practices. using news2 in the dental practice will help members of the dental team effectively, confidently and safely manage medical emergencies, should they arise. this will facilitate effective teamwork and ensure enhanced patient outcomes. ultimately, in line with gdc principle 1, the dental team will be working in the best interests of patients. 13 this article has provided an overview to news2 as well as some guidance on how to implement it. general dental council. scope of practice news) 2: standardising the assessment of acute-illness severity in the nhs national early warning score (news) (news) 2 to improve detection of acutely ill patients validation of the national early warning score in the prehospital setting can early warning scores identify deteriorating patients in prehospital settings? a systematic review association between national early warning scores in primary care and clinical outcomes: an observational study in uk primary and secondary care news 2: an opportunity to standardise the management of deterioration and sepsis the updated national early warning score and its use with suspected sepsis royal college physicians. news2 and deterioration in covid-19 dental mythbuster 10: safe and effective conscious sedation general dental council. standards for the dental team key: cord-314492-483rn3aw authors: gallagher, jennifer e.; johnson, ilona; verbeek, jos h.; clarkson, janet e.; innes, nicola title: relevance and paucity of evidence: a dental perspective on personal protective equipment during the covid-19 pandemic date: 2020-07-24 journal: br dent j doi: 10.1038/s41415-020-1843-9 sha: doc_id: 314492 cord_uid: 483rn3aw the global covid-19 pandemic, caused by the sars-cov-2 virus, has highlighted the importance of personal protective equipment (ppe) for health and social care personnel. this is a really important issue for dentistry, where we place great emphasis on infection control and universal precautions, given the nature of care provided. cochrane have recently updated their review of ppe for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. it examined evidence on which type of full body ppe and which method of donning (putting on) or doffing (removing) are most effective, while having the least risk of contamination or infection for healthcare workers, as well as which training methods increase compliance with ppe protocols. the objective of this paper is to raise awareness of the above review of ppe, its findings and their relevance to dentistry as outlined in the cochrane oral health website. the available evidence comes from healthcare generally, mostly involving simulation exercises, and is of low or very low certainty. none of the evidence specifically comes from dentistry. the findings in relation to the nature of ppe, methods of donning and doffing, and the importance of training are all of practical relevance to dentistry. research is critically important to provide evidence for future decision making in support of patients and staff. the global covid-19 pandemic, caused by the sars-cov-2 virus, 1 has highlighted the importance of personal protective equipment (ppe) for health and social care personnel. it is important to acknowledge from the outset that ppe has proved a contentious issue across health and social care generally across the united kingdom (uk), and beyond, and is one that will need to be resolved practically moving forwards. this is of critical importance to dentistry, where we have historically placed great emphasis on infection control and universal precautions, given the nature of care provided. based on evidence to date, the world health organisation suggests that transmission of the sars-cov-2 virus is mainly via respiratory droplet and contact routes, with transmission being possible through aerosol generating procedures (agps). 2 droplet transmission occurs when a person is in close contact (within 1 m) with someone who has respiratory symptoms (for example, coughing or sneezing) and is therefore at risk of having his/her mucosae (mouth and nose) or conjunctiva (eyes) exposed to potentially infective respiratory droplets. person-toperson transmission routes for covid-19 disease can involve direct and indirect contact, 2 and it is important to recognise that this coronavirus is present in saliva. 3, 4, 5 sars-cov-2 is a novel coronavirus and, because of the nature of their occupation, healthcare workers (hcws) are often at greater risk of infection than the general population. 6 deaths of colleagues across healthcare have highlighted these risks, leading to concern and calls for greater protection for staff. appropriate ppe offers an important way of reducing the risk of infection during the provision of healthcare. highly infectious diseases due to exposure to contaminated body fluids, in healthcare staff ' . 8 it reviewed contemporary evidence on 'which type of full-body ppe and which method of donning (putting on) or doffing (removing) ppe have the least risk of contamination or infection for hcw, and which training methods increase compliance with ppe protocols' . 8 the evidence from this review is of great importance where there is a risk of highly infectious diseases, and even though covid-19 is no longer considered to be a high consequence disease in the uk, 9 its findings remain relevant to the current pandemic 10 and continue to be updated. the objective of this paper is to raise awareness of the findings of the above review of ppe 8 and explore their relevance to dentistry, building on our commentary presented on the cochrane oral health website. 10 cochrane synthesises the best available evidence using rigorous methodology to answer specific research questions, thus drawing on the body of evidence available to inform decision-making, 11 using thorough methods. 12 the covid cochrane group are prioritising questions related to covid-19, 13 reviewing the literature and synthesising wide-ranging data in a matter of weeks rather than the usual extended period of at least two years. 14 groups have prioritised this task and are collaborating where interventions are common across profession groups or health conditions. it involves rapid peer review of protocols and search strategies, working many extra hours to complete them as quickly as possible without compromising their quality, with final peer review and editing before publication. one example is the fast-tracking of this review of ppe for all hcws. 7,8 current work by cochrane oral health includes rapid reviews of mouthwashes and nasal sprays, and methods to reduce aerosols produced during agps, as well as a rapid review of international dental guidelines for return to dental services. 15 the ppe review questions for hcws are relevant to the practice of dentistry and all dental professionals working in clinical settings, including dentists, dental hygienists, dental nurses, dental therapists, orthodontic therapists, dental technicians and clinical dental technicians, along with reception and cleaning staff and practice managers. 10 clinical members of the dental team work in close proximity, usually face-to-face, with patients and often for sustained periods of time. over and above the risk associated with proximity to potentially infected individuals, during routine care, they are exposed to saliva and blood and carry out agps (for example, use of high-speed air rotors and ultrasonic scalers). for covid-19, personal protection entails preventing droplets from entering their mouth, nose or eyes and preventing them from contaminating the skin elsewhere. this makes the findings of the review highly relevant to the dental profession. although there is no evidence to say that dental procedures increase the likelihood of patients coughing, if they do, clinicians are in close proximity. this further increases the chance of aerosol and droplet generation, as well as infected material settling on environmental surfaces and on ppe. while the search included a broad range of hcws, only 24 studies (controlled studies, either randomised or non-randomised) were included, most from simulation exercises and none directly associated with dentistry. 8 in the midst of an acute situation where the primary evidence is difficult, and probably impossible to generate with enough speed to be useful, a judgement has to be made on how confident we are that the findings of this review can be applied to the dental care setting. however, in the absence of direct evidence from studies situated in a dental setting, we have to take note of, and realistically apply, the general evidence. it is important to note that 'the certainty of the evidence presented in the review, 8 across all comparisons, was judged to be low or very low' 10 for a range of reasons. this related to the paucity of research addressing each of the questions, together with the fact that much of the available research involved simulations of exposure rather than research in real-life conditions, small sample sizes, high or unclear risk of bias and insufficient detail on whether the ppe used fitted international standards for protective clothing. 8, 10 furthermore, most of the research understandably used harmless microbes or fluorescent markers rather than microbes or viruses of concern. 8,10 nonetheless, its key findings, against which the questions were relevant to dentistry, are important given the above caveats (box 1). while it is important to acknowledge that 'members of the dental team are very experienced in the use of standard ppe, most work within primary care settings, and may be less familiar with the more extensive forms of ppe' , 10 although this is rapidly changing. the cochrane review suggests that 'covering more of the body' leads to 'better protection.' 8 this included gowns providing better protection than just an apron. 8 the evidence suggests that added coverage provided by a coverall (one-piece suit) when compared with a gown comes at a cost in terms of increased 'difficulty in doffing' such ppe. 8 while there were initial concerns that challenges with doffing increased the risk of contamination, current evidence suggests that, in 'more recently introduced full-body ppe ensembles, there may be no difference in contamination' . 8 the review also suggests that 'ppe made from more breathable material may help increase user satisfaction, with little impact on contamination. ' 10 the head and neck areas of the dental team are particularly at risk for hcws during clinical dental procedures. 10 thus, ensuring ppe coverage is adequate to protect these areas is an important aspect of its effectiveness; in addition, 'better fitting ppe' in this region, 'sealed gown and glove combinations' to protect wrists, and certain design features such as 'tabs to "grab" during doffing and donning' may help to reduce the risk of contamination. 8, 10 overall, ppe should provide full coverage but not be too cumbersome. it is important not to make the mistake of assuming that just 'having' face masks and other elements of enhanced ppe is 'good enough' . dental professionals also need to be aware of the risks of contamination associated with donning and, in particular, doffing ppe. space for these processes will need to be considered as part of dental surgery organisation where care is being delivered, as well as the time involved. training in donning and doffing is particularly important for dental teams who may not wear this type of ppe for routine practice or who may need to learn new, safer habits carefully. the presence of an observer, in particular for doffing ppe, should be considered. teams should consider face-toface training opportunities as they may reduce the likelihood of errors, alongside computer simulation or videos which may also support these skills. 8,10 the cochrane review makes a strong case for building evidence to inform decisions on the 'most appropriate manageable protection' , 8 including 'modifications for hcws' . 8 we concur that this is essential for dentistry, if dental teams are to deliver care safely. 10 it also 'provides helpful insights on the research required, and the importance of registering and coordinating research with comparable outcomes' . 10 we need to consider how we can best do this across the four nations of the uk and connect with our global partners who are also facing the same issues. there is an opportunity, during this covid-19 outbreak, to use the natural experimental setting that dental care centres provide to create the evidence we need on health outcomes and personnel involved. 10 these opportunities include, but are not limited to, the issues of viral transmission rates, those related directly to the training, education and use of ppe, as well as how this affects patient care. 8, 10 trials in dental care settings safe provision of dental care requires a deep understanding of pathogen transmission and how it relates to the various types of care provided; for example, agps and non-agps. 10 trials using high-quality and standardised methodology considering the spread and settle of demonstration pathogens or surrogate measures in dental settings are key, and these should consider the array of different procedures that are considered to generate aerosols. it is worth noting that fluorescent dyes or harmless bacteria and viruses have been used for much of the higher quality simulated research in the past. 8 they should include all relevant settings and consider single and multiple surgeries as well as laboratories and domiciliary care. 10 studies should be well-designed and of sufficient sample size, with agreed outcomes. 8 crossover studies should be conducted where possible. details of education and training, fit testing, equipment used (including standards), dental examination and special investigations and procedure(s), length of appointment, nature of patient(s), technique of dental care, donning and doffing processes, environment and a range of outcomes should be recorded. 10 we need to know the most appropriate type of ppe for clinical encounters with different potential exposure levels. for example, it would be helpful to confirm whether standard ppe is adequate for an oral examination while more elaborate ppe, even with its drawbacks, is necessary for treatments where aerosols are actively generated during the procedure. also, are the types of ppe required for dental professionals carrying out routine care during peak phases of the covid-19 pandemic still required for the post-peak phase? in addition, there needs to be an understanding of the amount of time that recommended ppe can be worn comfortably. simulation exercises involving comparison of different levels of ppe will be particularly helpful to inform standard requirements for different aspects of dental care. 10 this includes the effect of masks, face shields and goggles. 10 furthermore, we will also need to consider shielded patients and the best way of affording them the necessary protection as well as staff. while we have considered the review in a dental context, we currently lack critical knowledge on whether viral load and shedding are similar in asymptomatic individuals 16 and to what extent this presents a risk in dentistry. 17 evidence in these areas would allow better understanding of appropriate ppe. we also need to deepen our understanding of aerosol generation generally, 18 as well as specifically in relation to viruses in dental settings. given the burden of oral disease 19 and the evidence that transmission of sars-cov-2 by seemingly well individuals (pre-symptomatic and asymptomatic), we need to seriously consider how our patient and population needs are best met for the future. models indicate that pre-symptomatic individuals alone may account for 30-62% of events (confirmed covid cases). 20, 21, 22, 23 it is important to remember that most patients attending for dental care will be covid-negative. important questions are being debated regarding the nature and extent of universal precautions, and whether we should adopt a precautionary principle to protect our dental teams and patients until more is known and these can be confidently relaxed. measures such as self-isolation and testing are now being suggested to reduce risk associated with planned and urgent care in key findings: • coverage: there is better protection from covering more parts of the body, but this has to be balanced against the possible increase in risk of contamination associated with difficulty donning or doffing, as well as less user comfort hospital settings. 24 ppe should be considered after risk assessment and as just one issue in a larger preventive approach, including aerosol, droplet and splatter reduction and ventilation. risk reduction must be considered along with other major challenges to our staff 's health and wellbeing, including the nature of care and the complex business of dentistry. we do not have all the answers about universal precautions for the future, but all dental professionals will need to take action in identifying and managing risk in line with national guidance and learning from our colleagues around the world. we have to be able to justify our actions in managing risk, and collect evidence and be prepared to adapt where necessary. having ppe is important, but so is wearing it properly and removing it safely; it is important to remember that ppe is just one way of protecting dental professionals and patients, all of which require careful consideration and research to inform our journey back to what may become a 'new normal' . naming the coronavirus disease (covid-19) and the virus that causes it modes of transmission of virus causing covid-19: implications for ipc precaution recommendations temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by sarscov2: an observational cohort study consistent detection of 2019 novel coronavirus in saliva human saliva: non-invasive fluid for detecting novel coronavirus (2019-ncov) epidemiology of and risk factors for coronavirus infection in health care workers personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff high consequence infectious diseases (hcid) -status of covid-19 personal protective equipment: a commentary for the dental and oral health care team about cochrane reviews cochrane handbook for systematic reviews of interventions half of cochrane reviews were published more than two years after the protocol available at https:// oralhealth.cochrane.org sarscov2 viral load in upper respiratory specimens of infected patients bacterial aerosols in dental practice -a potential hospital infection problem? editor's commentary: rapid reviews of ppe -an update global burden of oral conditions in 1990-2010: a systematic analysis quantifying sarscov2 transmission suggests epidemic control with digital contact tracing substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov2) estimating the generation interval for covid-19 based on symptom onset data temporal dynamics in viral shedding and transmissibility of covid-19 operating framework for urgent and planned services in hospital settings during covid-19 professor a. m. glenny, cochrane oral health. key: cord-010856-3g0123lk authors: araghi, ariyan s.; harris, yasmin; kyzas, panayiotis title: an audit to analyse the two-week wait pathway at an oral cancer specialist district general hospital date: 2020-05-08 journal: br dent j doi: 10.1038/s41415-020-1449-2 sha: doc_id: 10856 cord_uid: 3g0123lk background the incidence of head and neck cancers is increasing, alongside a decrease in associated mortality. currently, medical and dental practitioners can refer patients to be seen urgently within two weeks. the appropriateness of these referrals has been disputed. in 2020, the department of health aims for patients to be given cancer diagnoses within 28 days from referral. methods a retrospective audit was conducted for all patients referred under the two-week wait pathway in a six-month period. in the first cycle of this audit, one month's worth of urgent referrals were analysed; given the small sample size, very few recommendations could be made. the audit cycle was repeated and it analysed six months' worth of data, which gave a much more representative study. all patients were analysed to see if the 14-day period had been breached. positive cancer patients were further assessed to see if their diagnosis had been given within 28 days and treatments within 62 days. results of the 569 patients seen, there was a positive malignancy diagnostic yield of 7.38%. nineteen patients breached the 14-day wait. of the positive patients, 45.2% received their diagnosis more than 28 days from referral, and 22.2% of these patients received treatment after 62 days. conclusion the department performed well despite the high number of referrals. this audit has touched on some key issues which have been discussed in detail in this article. furthermore, this audit recommends a concerted effort to improve oral cancer detections skills among gdps and gmps. while all referrals may be appropriate from a primary care point of view, this audit makes it apparent that better differentiation is needed between malignant and routinely manageable lesions. all secondary care units alongside general practitioners can learn from the findings of this audit. the incidence of head and neck cancers (hncs) in the uk is rising. the necessity of early and appropriate recognition of patients at risk is incredibly high. the national institute of health and care excellence (nice) have released guidance for the recognition of symptoms that warrant further investigation. cross-pathway referral for these cancers allows both general medical practitioners (gmps) and general dental practitioners (gdps) to refer patients to be seen within two weeks by a specialist secondary care consultant in an oral maxillofacial cancer unit. despite this, the positive diagnosis percentages of these cancers after referral remains very low. this low percentage is a promising variable on a patient level; however, it highlights an area of education for the wider team. additionally, when compared with neighbouring european countries, the mortality one year post-diagnosis is lower in the uk. this calls into question the appropriateness of the urgent two-week wait (2ww) referral pathway for these cancers and its efficiency in triaging patients from primary care to secondary care. as part of the nhs long term plan, the department of health have decided to implement a new target for potential cancer patients, which aims to intercept and treat cancer sooner. in 2020, all cancer diagnoses should be given within 28 days from the initial referral, thus shifting the importance from date of secondary care consultation to date of diagnosis. the details of the nhs long term plan are touched on in more detail later on in this article. this project is a retrospective audit of all the patients referred to the head and neck team at north manchester general hospital under the urgent 2ww referral for suspected hncs in a six-month period. this study has the following aims: 1. to assess whether all of the patients referred are being seen in the required 14 days, according to the current '2ww' guidelines this audit aims to elaborate on what happens once a two-week wait urgent cancer referral is made. it elaborates on the process and more specifically the timeframe from referral to initial treatment. it brings the reader's attention to upcoming changes to the timeframe in which oral cancer patients must be seen, diagnosed and treated as per the nhs long term plan (2020). it also touches on some of the barriers that exist to aid in the early detection of this disease. 2. to assess the positive diagnostic yield of cancer in this group of patients 3. of the positive cancer patients, to assess whether they are being given treatment within 62 days and ascertain what treatment is being given 4. to analyse whether the positively diagnosed cancer patients were being given their initial diagnosis within 28 days, in preparation for the new guidelines to be implemented in the nhs long term plan (2020) 5. to help develop guidance in which a nationalised plan can be utilised to ensure maximum treatment efficacy for urgent cancer referrals. the standard set for this audit would be that 100% of the patients were being seen initially in 14 days. one hundred percent of the patients positively diagnosed with cancer would receive diagnosis within 28 days and subsequent treatment within 62 days in line with the current guidelines for the 2ww referral system for hncs. the standard for diagnostic cancer yield/positive oncological transformation would be set at 3%, as appropriate for a screening test as set out by nhs england. in the uk, the incidence of hncs has doubled since 2006 and 2010, with the number of new diagnoses continuing to increase. 1 hncs in general have five-year survival rates of 55% in the uk. 2 the outcomes are known to be worse the more advanced the disease is picked up. in an attempt to ensure that hnc patients are being seen and treated efficiently, in 2000, the department of health (doh) released guidance that should be adhered to when referring patients with an urgent suspicion of cancer. this is termed the 2ww pathway. 3 the typical journey for a patient positive for hnc is highlighted in figure 1 . as shown, it aims for patients referred under the 2ww pathway to be seen by a secondary care specialist consultant within 14 days. the patient's first definitive treatment (fdt) -that is, surgery and chemotherapy -should be within 62 days. 3 hncs can vary widely in their presenting symptoms. in order to identify patients at risk, the nice published a set of guidelines (ng12) highlighting symptoms that warrant a 2ww referral. 4 both gmps and gdps can choose to refer patients with the following symptoms: 1. laryngeal cancer: persistent unexplained hoarseness or unexplained lump in the neck in patients aged over 45 2. oropharyngeal cancer: unexplained ulceration in the oral cavity for over three weeks or a persistent and unexplained lump in the neck 3. thyroid cancer: an unexplained thyroid lump. 4 the guidelines were reviewed and updated in 2017 for gmps to refer to gdps for a second opinion, rather than direct 2ww referral, in the following cases: • a lump on the lip or oral cavity • a red, or red and white, patch in the oral cavity consistent with erythroplakia or erythroleukoplakia. 4 the update also removed the requirement for the oral cavity patch to be painful, swollen or bleeding. this increases the number of patients that would be 'appropriate' to refer. 5 the aim of the 2ww referral system is to be a screening tool for malignant disease. therefore, it can be reasonable to expect a 10% positive oncological transformation/malignant diagnostic yield. however, when developing the guidelines for referral, it is important to also take into account departmental resources and balance this with a potential large amount of patients that are deemed to be appropriate to refer. langton et al. conducted a systematic review of 17 studies showing all patients referred from 2000 to 2014 under the 2ww for hncs. the review showed that the proportion of patients diagnosed under the pathway was decreasing and that the positive diagnostic yield of the 2ww pathway remained low between all studies. his review showed that there has been an increase in the number of referrals, without an increase in the number of diagnoses, which can potentially put immense burden on already busy secondary care departments. langton's study further demonstrated a 60% increase in referrals between 2001-2004, which resulted in departments being unable to see patients within the two-week timeframe. 6 in terms of patient experience, the 2ww was very beneficial as patients felt that they were being seen quickly and thus felt more in control of their diagnosis. 6 more recent audits from other major head and neck centres have added to these findings. a recent audit from a head and neck cancer unit in glasgow showed that, in one year, 7.6% of patients referred under the 2ww pathway were positive for a primary hnc. 7 pindolia et al. showed that 96% of the 2ww referrals in a major london head and neck centre were nonmalignant, instead resulting in diagnoses such as oral lichen planus and recurrent aphthous ulceration (47% and 14%, respectively). 8 this questions whether the 2ww pathway is being overused by referring practitioners. roy et al. questioned whether the increase in referral numbers could be due to the fact that not many practitioners will see this type of cancer or have had the education, training or exposure to it; therefore, they will be more likely to refer for any symptoms suggestive of hnc. their research further highlighted that some referrals had been made without consulting the nice guidelines at all. 9 on the subject of guidelines, one could argue that the current nice guidelines require further re-evaluation. tikka et al. analysed the presenting symptoms of patients with positive cancer diagnoses and compared these with the nice referral criteria. statistical models identified nine symptoms highly linked with hnc, only four of which are in the criteria. 10 research has been done to introduce a web-based prediction score for patients with suspected hncs. this would help practitioners to identify at-risk patients, concentrating on risk factors and symptoms, generating a risk score. 11 due to the cross-pathway referral system, there could be a difference in the group of referring practitioners, suggesting that a certain group requires more education in terms of referral. shanks et al. showed that 73% of medical students asked had not been taught how to examine the oral cavity. 12 in comparison, there have been highly detailed examination guidelines released for gdps in dental journals for the positive identification of oral cancers. 13 however, when reviewing audit results, there seems to be discrepancies. hong et al. demonstrated 148 referrals from gmps and 9.5% positive malignancy pick-up, compared with 72 referrals with 1.4% pick up from gdps. 14 roy et al. also showed that 55% of their referrals were from gmps. 9 in contrast, pindolia et al. showed the majority of referrals to their hnc centre to be from gdps. 8 there is lots of conflicting and somewhat convoluted research in this area; thus, it would be safe to say a head and neck detection toolkit would be most useful for both gdps and gmps. though the 2ww is a very well-established target nationally, the uk government has decided to implement a new set of guidelines in the treatment of cancers. in the nhs long term plan published in january 2019, a 'faster diagnosis' guideline was introduced. 15 the changes to patient journey are highlighted in figure 2 . the main change will be the focus on giving patients their cancer diagnosis within 28 days of the urgent suspected cancer referral. this is to be implemented in all sites by 2020. 15 this change is stated to aim to improve patients' quality of life, decreasing the time in which they are feeling anxious and starting the required treatments as soon as possible. the 62-day timeframe for fdt is to remain in place. 15 pubmed and medline database searches were used to assess what literature already exists around this subject area. the following terms were used in the search: 'head and neck cancer' , '2 week wait' , '2-week referral' , 'uk' , 'fourteen day' , 'oral cancer' , 'pharyngeal cancer' , 'gp referral' , 'maxillofacial referral' , 'oral cancer diagnosis' and 'oral cancer classification' . the nice website was used to access the most recent guidelines for the urgent referrals. the nhs england website provides the documentation with the most recent cancer waiting times and the nhs long term plan. the patient inclusion criteria were all patients referred under the 2ww pathway for urgent suspected hnc to north manchester general hospital in the six-month period between september 2018 and the end of february 2019. patient data was obtained through the hospital data collection team; there was no need for ethical approval as patient outcomes were not affected in this retrospective audit. local governance standards were met after a formal request was made around the audit subject area. the data provided from the hospital database outlined the below seven parameters -these parameters allowed us to conduct the audit, and compare and contrast the journey of patients from referral to consultation and beyond. parameters to be assessed were: as alluded to earlier on in this article, the journeys of one month's worth of patients who were referred on the 2ww rule were analysed; the sample size was too small to give a representative conclusion as to what recommendations could be made going forward. the second round of data collection incorporated six times as much data and, as a result, several conclusions were made. patients fell into one of two groups during the data collection: those who were taken off the cancer pathway and only matched parameters 1-4, and a second group who remained on the cancer pathway and went on to match parameters 4-7 above. the data analysis was carried out by a junior member of the surgical team and presented at a local departmental governance meeting within the specialist cancer hospital. the data collection process was not able to differentiate between type and severity of oral cancer -that is, we will not be able to tell the difference between a t1n0m0 (small tumour) and a t4n1m1 (large tumour with metastatic disease). this audit did not aim to distinguish between different cancer types, but rather to solely assess the timeframe in which patients are seen with regards to the 2ww pathway. it is unlikely that type and size of tumour should play a part in the time pathway of the diagnostic oral cancer journey; however, this audit has highlighted that this could be a variable in the journey, therefore signposting an area of potential review in the future. when both rounds of data collection were completed, analysing data from august 2018 and then in the second cycle from september 2018 to march 2019, 603 patients were referred to this centre under the 2ww pathway. thirty-four patients did not attend their appointments and therefore were erased from the data to be analysed. therefore, 569 patients were seen in the head and neck department for urgent suspected cancer. the data showed that 19 patients of the patients seen in the department breached the 2ww (3.34%). all of these were due to patient choice except for one case, which was the sole case due to departmental capacity issues. this patient was seen in 23 days and the ultimate forty-two out of 603 patients were positively diagnosed with cancer (7.38% malignancy yield) in the data analysed. figure 3 shows the frequency of each diagnostic investigation. three of the 42 positive cancer patients (see fig. 3 ) had no initial investigations. of the 32 ct scans requested, 16 were positive for cancer (the highest diagnostic yield of 50%). despite being the most requested investigation, the incisional biopsies were positive for cancer in 11 cases (8.9%). analysis of the date of diagnosis showed that 19 of the 42 positively diagnosed patients (45.2%) had been diagnosed after the target of 28 days. the distribution of timings for each group of dates can be seen in figure 4 . the mean time between referral and diagnosis was 28.4 days, with standard deviation of 13.6. the most that a patient waited for a diagnosis was 64 days, seen in figure 5 . five patients were not given a definitive treatment and one patient was awaiting surgery, which left 36 of the 42 cancer patients with treatment. eight patients breached the 62-day period (22.2%), and the results of each group can be seen in figure 6 . comparing the fdt date with the date of diagnosis revealed that five of the eight patients who had passed the 62-day fdt target had also failed to reach the 28 day target for diagnosis. figure 7 shows the distribution of treatment types given to these patients and their frequencies. the unit received referrals for over 100 patients per month. it was interesting to note the 34 patients who did not attend their consultations for suspected cancer. this could be tackled by increasing communication in primary care about the importance of these consultations and explanation that this could be a potentially malignant disease. before this, practitioners the data has shown that the unit is very familiar with the 14-day wait and has been able to deal with the large number of patients well, with only one breach in all 569 patients being due to lack of departmental space. further investigation is required into the exact reason for this delay, which resulted in a 23-day wait. the team are able to meet well-known targets and also accommodate the 18 patients that need to delay their consultations. the average waiting time is very short. the longest that a patient had to wait for their initial consultation was 34 days, again due to personal choice. the one patient that had breached the 14-day period with an ultimate cancer diagnosis is the same patient that had a 117-day delay between referral and fdt (fig. 7) . this patient had also been diagnosed at 41 days after referral (fig. 5 ). this questions whether there had been some special circumstances in this one patient which required certain delays. this would be something that could benefit from further case-specific investigation. the patients were being investigated appropriately, with the majority of patients sent for initial diagnostic investigations. figure 3 shows that 159 patients altogether were subjected to biopsies. the fact that the diagnostic yield for patients sent for ct scans was so high means that the consultants are appropriately sending patients for the correct investigations. this shows us that more worrying patients are sent for ct scans as they are more likely to be malignant after initial clinical history and examination. incisional biopsies are ordered when histology is required for the diagnosis, resulting in a lower yield. the malignancy yield from this cohort of patients was low at 7.6%. this is in keeping with the audits and reviews from other sites, further questioning the 2ww pathway symptom guidelines. 7, 8, 9 there is no dispute in the necessity of patients being seen promptly for suspected hncs. however, this does highlight the high sensitivity and low specificity of the 2ww as a screening tool. many patients are being seen, resulting in more diagnoses. this is very positive, but only because the unit have proven to be prepared to handle such a large number of patients. is there a way to decrease the number of patients being seen, while keeping the high sensitivity of positive diagnoses? the question lies with the referring practitioners. as previous research has shown, there is a possibility of bringing in a more detailed online referral system. 11 research has shown that improved communication between the referring practitioner and the secondary care consultant could stop patients that are not at risk from being seen. 14 a preliminary suggestion is that an online toolkit should be developed to help practitioners definitively diagnose high-risk lesions, as the current system is proving inefficient in this sense. there are some toolkits that are available online, these are sign posted later on in the discussion; going forward from this, every effort should be made to raise awareness of these educational tools. ultimately, these methods both rely on improving the education of the referring professional. it is possible that adequate training is not being given to gmps and gdps for the referral of oral lesions. as mentioned in previous studies, referring practitioners may have a low tolerance for referral under the 2ww due to the worry of missing malignant conditions that they are not familiar with, and the potential repercussions to both patient health and their own professional record. 9 it does state in the nice guidelines that referrals for oral lesions can be done via a second opinion with a gdp. 4 however, the literature states that the majority of referrals were via gmps, this brings into question whether the cross disciplinary protocol is being adhered to or not. 9, 14 in hindsight, it would have been useful to compare the numbers of referrals and subsequent malignancy yield of referrals from gmps and gdps -this could be an area that we visit in a future study. from the work conducted by shanks et al., it is evident that further education in terms of oral cavity examination is required for medical students. 12 it seems as though the medical curriculum has overlooked this topic for undergraduate medical students. 13 undergraduate educators should consider the importance of overlooking this area of teaching and incorporate essential oral pathology/oncology into the undergraduate curriculum. the target for having a cancer diagnosis within 28 days from referral was poorly met, being achieved in only 54.8% of cases. this is far off the 100% set standard. figure 4 shows us that the majority of patients that were seen after this target were at least diagnosed within 42 days (15 patients), and in four cases this was over 42 days. figure 5 shows us that even the mean time for diagnosis was 28.4 days, greater than the target. it is important to realise that, according to the previous guidelines, all of these patients (apart from the one that has been mentioned previously) had reached the 14-day referral target. however, they still had been given a fairly late diagnosis, thus failing to reach the new cancer target for the nhs long term plan (2020). departmental and institutional understanding of this target must be assessed. diagnosis date mainly relies on two things: the administrative team being able to book in and accommodate patients for follow-up appointments, alongside the radiology and histopathology teams being able to conduct relevant investigations and report on these promptly. the department have been able to do this for the majority of patients, however it has proved increasingly difficult as the number of urgent referrals are very high. units are now pooling services and joining forces with other hospitals to help share the workload and ensure patients receive timely interventions. for example, several hospital units have joined forces in the north west and review all hncs together. this shared workload, increased availability of resources and greater secondary care expertise is ensuring that patients are receiving the correct intervention within the right time frame, this is now known as the 'pan hospital mdt scheme' . another recommendation is for the oncology leads in similar units to put together a focus group, ensuring that, nationwide, all departments will have the know-how and ability to be compliant with the nhs long term plan. the statistics for fdt dates were positive; however, as only 77.7% of patients were being treated within 62 days, the standard set of 100% was not met. the distribution seen in figure 6 shows us that the department were able to treat seven patients very rapidly, with fdt being below 28 days. these patients had been treated with surgery in five cases, active monitoring and palliative care. therefore, it is possible for procedures to be scheduled. essential to note is that all of these patients had been given a diagnosis in less than 28 days. the comparison between diagnosis date and fdt has shown a link, as five of the eight breaches of 62-day fdt had also breached the 28-day diagnosis. however, this is not necessarily causative, as of the 19 cases that breached the 28-diagnosis target, only five had later treatments. this does further support the nhs long term plan (2020), with earlier diagnosis hopefully leading to earlier effective treatment of these patients. further investigation regarding the two outlier patients with waiting times over 100 days would be required (fig. 7) . it is possible that, as the fdt for both of these patients was surgery, the wait could be due to the availability of high-dependency unit beds or other common causes of operation delays. the other cases that breached 62 days were due to chemoradiotherapy centre waiting times and active monitoring. looking at figure 7 , the proportion of fdts is unsurprising, with the vast majority of cases resulting in the need for surgery. this project has highlighted that the head and neck unit at north manchester general hospital is meeting the 2ww target well, despite having a very large cohort of patients. the low malignancy diagnostic yield from this retrospective audit has added to previous centre audits in questioning the appropriateness of using the nice referral symptoms alone for identification of hncs. there needs to be further education for referring primary care practitioners, both gmps and gdps. this has already been tackled in part by the development of a new model for simplifying the management of oral cancer patients. we would encourage the reader to refer to the following resource: 'the reconstructive oral cancer patient: what the general dental practitioner needs to know' (2019), 16 and the plethora of information it posts the reader to in aiding with proper oral cancer care and diagnosis. although patients were mainly receiving their fdts in adequate time, a large proportion were not meeting the 28-day diagnosis timeframe. hopefully, with the awareness generated from presentation of these results, this will be improved in preparation for the upcoming nhs long term plan. in the current pandemic that we face, we have been trialling a new method for seeing hnc 2ww patients. we are requesting that a photo is sent in with any suspicious lesion alongside the referral, this allows us to expedite or delay clinic appointments according to the what the photos shows us. the limitation of this is that is does not account for non visible signs of hnc such as dysphonia, dysphagia or otalgia. however, our experience to date has showed us that this reduces hospital foot flow and highlights the patients who definitively require investigation. once this subgroup arrive, we have created a one step clinic where a consultation, exam and possibly biopsy will be performed in the same visit. the aim of this is to again reduce hospital visits for patients, moreover it ensures that the next visit will entail diagnosis and initial treatment planning. this new modality shows us that we are well in line with the nhs 2020 long term plan. it is hoped that the reader realises that the onus for correct management and succinct diagnosis relies on the original referrer. the world health organisation (who) has long battled for a universal screening programme for oral cancer detection; this outcry has yet to prove successful. 17 the uk national screening committee have a 20-step checklist before allowing nationwide enrolment of a screening programme; multiple suggested oral cancer screens have all failed to meet the required number of criteria to allow progression into experimental trials and eventual nationwide screening. we would encourage the reader to familiarise themselves with the work of brocklehurst et al., 17 who review the advantages and disadvantages of oral cancer screening, analysing the complex health economics of the matter. the following recommendations have been summarised as a result of this audit and it is hoped that all members of the wider healthcare team can gain from the conclusions below: • to try and develop a focus group to create guidance for the uk-wide clinicians regarding the 2020 nhs initiative • to develop a series of educational lectures for undergraduate medical students to inform them about basic oral pathology and oncology. this could be done by adding to the undergraduate medical curriculum • an online toolkit should be developed to help ensure that the correct lesions are being sent in on the 2ww system. the available systems by cancer research uk and the bda should be expanded on and publicised more • ultimately, this audit has shown that the 2ww urgent referral system is being overused. one would hope that the readers of this audit realise the importance of updating their knowledge in oral cancer detection and diagnosis. this will have a positive impact on a multidimensional basis; patients have the best chance of early detection and definitive cure, the referral system can be used to triage suspicious lesions only, and non-suspicious lesions can be managed locally, thus removing strain from the already convoluted hospital system • this audit will be repeated in the coming years after the nhs long term plan has been fully implemented; it would be useful to see if the aforementioned analysis and suggestions will have a positive impact on first treatment dates. oropharyngeal cancer: united kingdom national multidisciplinary guidelines profile of head and neck cancers in england: incidence, mortality and survival waiting times for suspected and diagnosed cancer patients: 2016-17 annual report referral guidelines for suspected cancer new nice referral guidance for oral cancer: does it risk delay in diagnosis? two-week rule in head and neck cancer 2000-14: a systematic review outcomes of urgent suspicion of head and neck cancer referrals in glasgow a review of the utilisation of the 2weekwait referrals in a large maxillofacial unit in london the two-week wait -a qualitative analysis of suspected head and neck cancer referrals refining the head and neck cancer referral guidelines: a two centre analysis of 4715 referrals a web-based prediction score for head and neck cancer referrals oral cavity examination: beyond the core curriculum? mouth cancer: presentation, detection and referral in primary dental care two-week wait false alarms? a prospective investigation of 2ww head and neck cancer referrals the nhs long term plan the reconstructive oral cancer patient: what the general dental practitioner needs to know screening for mouth cancer: the pros and cons of a national programme key: cord-337904-q90ftaht authors: shah, sagar; wordley, valerie; thompson, wendy title: how did covid-19 impact on dental antibiotic prescribing across england? date: 2020-11-13 journal: br dent j doi: 10.1038/s41415-020-2336-6 sha: doc_id: 337904 cord_uid: q90ftaht introduction antibiotic resistance is a global problem driven by unnecessary antibiotic use. between 25 march-8 june 2020, covid-19 restrictions severely reduced access to dentistry in england. dental practices were instructed to manage patients remotely with advice, analgesics and antibiotics, where appropriate. aim to describe the impact of the policy to restrict dental access on antibiotic prescribing. methods nhs business services authority 2018-2020 data for england were analysed to describe national and regional trends in dental antibiotic use. results antibiotic prescribing in april to july 2020 was 25% higher than april to july 2019, with a peak in june 2020. some regions experienced greater increases and for longer periods than others. the increase was highest in london (60%) and lowest in the south west (10%). east of england had the highest rate of dental antibiotic prescriptions per 1,000 of the population every month over the study period (april to july 2020). conclusion restricted access to dental care due to covid-19 resulted in greatly increased dental antibiotic prescribing, against an otherwise downward trend. as dental care adapts to the covid-19 era, it is important to ensure access for all to high-quality urgent dental care. understanding the reasons for variation will help to optimise the use of antibiotics in the future. antibiotic resistance is a major public health burden driven by the use of antibiotics. 1 severely restricted access to dental care during the early stages of the covid-19 pandemic led to a significant increase in antibiotic prescribing by dentists. 2 on 25 march 2020, dental practices in england were instructed to suspend all routine, non-urgent dental care and all emergency dental care was provided through a network of local national health service (nhs) urgent dental care systems. 3 dental practices were restricted to providing remote management of patients by telephone and were advised to provide advice, analgesics and antibiotics (the aaa approach), where appropriate. 3 on 8 june, practices were permitted to commence reopening for face-toface care while ensuring adherence to covidrelated safety measures. 4 this resumption of services occurred over a period of weeks and concerns have been raised about the backlog of routine dental care which accrued during the period of restricted access. 5 a report by the uk parliament's house of commons health and social care committee about the impact of the covid-19 pandemic on nhs services states: 'patients have been remotely prescribed with antibiotics for their dental problems but have returned with pain or further swelling as the cause of their dental problem has not been properly addressed…this is contributing to an "overhang of oral healthcare"' . this confirms the adage 'antibiotics do not cure toothache. ' yet, before covid-19, high rates of dental antibiotic overprescribing were identified, with 80% unnecessary use (not in accordance with guidance) reported in both the uk 6 and us. 7 dental guidelines for the treatment of dental infections are generally based on the principle of draining infections and removing the cause, which may necessitate a dental extraction or extirpation. 8, 9 antibiotics are usually reserved for the treatment of severe dental infections (such as extraoral facial swelling) with systemic complications (such as pyrexia). 10 in the absence of infection, antibiotics are inappropriate, yet studies and audits consistently show that dentists prescribe them for conditions such as irreversible pulpitis. 11, 12, 13, 14 a variety of approaches to optimise dental antibiotic prescribing across england have been developed and, in 2016, they were brigaded into a dedicated, national, online dental antimicrobial stewardship toolkit. 15 a downward trend in dental antibiotic use since 2011 has been reported in england. 16 with restricted access to face-to-face dental services during the covid-19 pandemic and the aaa approach advocated for remote management of patients, the aim of this study was to describe the impact of the policy to restrict access to dental services in england during the covid-19 pandemic on nhs dental antibiotic prescribing. the objectives of this study were twofold: to describe trends in overall dental antibiotic use across england between january 2018 and july 2020; and to compare trends in the rate of use between the seven nhs england regions, from when restrictions were first placed on face-toface dental care to the most up-to-date data available (april 2020 to july 2020). the number of antibiotic items (bnf section 5.1 -'antibacterial drugs') dispensed by community pharmacists in england relating to nhs dental prescription (fp10d) forms from january 2018 to july 2020 were provided by the nhs business services authority (nhsbsa). 17, 18 the datasets exclude prescriptions dispensed from prisons, hospitals and private prescriptions. the data are publicly available from the nhs under the uk freedom of information act 2000. the nhsbsa datasets are under crown copyright and their use is licensed under the terms of the 'open government licence for public sector information'. 19 the mid-year population estimates were obtained from the uk office for national statistics. 20 as population estimates for 2020 had not been published at the time of the analysis, population figures for 2019 were used for calculating the rates of dental antibiotic prescribing for 2020. as the data were obtained from national data resources and completely anonymised, ethical approval was not required. three outcomes are reported: 1) the total number of antibiotic prescriptions dispensed by community pharmacists to nhs dental patients in england each month between january 2018 and july 2020; 2) the national rate of prescribing per 1,000 of the population; and 3) the monthly rate of prescribing per 1,000 of the population for each of england's seven regions (east of england; london; midlands; north east and yorkshire; north west; south east; and south west). a downward trend in the number of antibiotic prescriptions dispensed to nhs dental patients was seen through the study period until march 2020 (see figure 1 ). after dental practices were restricted to providing only remote management of patients with aaa in late march, a sharp upward trend occurred during the months of april to june 2020. after dental practices were able to reopen in june 2020, the number of antibiotic dispensing to nhs dental patients plateaued in july 2020. the total number of antibiotic items dispensed for the period of april to july was 25% higher in 2020 compared to 2019 (1,095,486 vs 878,993). the average monthly rate of nhs dental antibiotic prescriptions was 4.1 items dispensed per 1,000 of the population in 2018 (see table 1 ). it reduced to 3.9 in 2019 and then increased to 4.5 for the period of january to july 2020. at the beginning of the period of covid-19 restrictions (april 2020), the monthly rate of dental antibiotic prescriptions was 4.1 per 1,000 of the population across england, ranging from 3.4 prescriptions in london to 5.0 in the east of england region. at the end of the study period (july 2020), the monthly rate was 5.3 per 1,000 of the population across england, ranging from 4.3 prescriptions in the south west region to 5.8 in the east of england. the rate peaked at 5.31 in june (28% higher than in april) before it reduced very slightly in july. as shown in figure 2 , all areas saw an increase in may and june 2020. two regions (london and south east) continued to rise in july, albeit the rate of increase slowed. overall, the highest rate of antibiotic dispensing to nhs dental patients occurred in east of england during june (6.1 antibiotic prescriptions per 1,000 of the population). the lowest rate was in london during april (3.4 antibiotics per 1,000 population). london also saw the highest increase, with just over 60% more antibiotics in july than april 2020. in july, the lowest rate was in the south west (4.3 per 1,000 population) which also saw the smallest increase between april and july (less than 10%). restricted access to dentistry due to covid-19 has resulted in increased dental antibiotic prescribing across england. the impact has affected antibiotic prescribing rates differently between the regions, with the peak rate higher and taking longer to occur in some regions. by july, the overall rate of increase nationally had plateaued and some of the regions had already returned to levels of antibiotic use below that in april. dentistry has an essential role to play in tackling antibiotic resistance, including by reducing unnecessary antibiotic prescribing. unnecessary dental antibiotic prescribing is a complex behaviour which is influenced by a plethora of clinical and non-clinical factors which affect dentists and patients. 21, 22 early in the covid-19 pandemic, a selection of potential factors driving the increase in dental antibiotic use were identified in a letter to the british dental journal editor-in-chief. 2 access and other systems/process issues were hypothesised as key, noting in particular that some urgent dental centres had been requiring patients to have tried antibiotics before accepting referral for face-to-face care. further research to interpret the variation found between the regions will follow. monitoring of dental antibiotic prescribing is an essential element of evaluating efforts to optimise dental antibiotic prescribing. no data of sufficient quality for this purpose is currently routinely collected in england at the level of individual dental practices, clinicians or patients. the introduction of e-prescribing for dentistry, as advocated by the national institute for health and care excellence in its 2016 antimicrobial stewardship: quality standard, 23 would facilitate this and should be an essential component of antibiotic stewardship approaches in the future. a comparison of covid-19's impact on dental antibiotic prescribing in other countries is not yet possible. it is anticipated, however, that countries where guidelines indicate prophylactic use of antibiotics by dentists to protect people who may be at risk of distant site infections (such as infective endocarditis) 24,25 may see a net reduction in antibiotic prescribing related to a reduction in the provision of routine dental care. in england, levels of prophylactic dental antibiotic use are known to be extremely low, 26 as guidelines do not recommend the routine use of prophylactic antibiotics. 27 for this reason, england may see a larger increase in overall dental antibiotic prescribing than other countries due to minimal offset from reductions in prophylactic use from reduced routine dental care provision. even before covid-19, there was evidence of significant overprescribing of dental antibiotics internationally. 7, 28, 29, 30 approaches to address unnecessary and inappropriate antibiotic use are urgently required in dental practices. the fdi world dental federation white paper, published in november 2020, advocates three roles for dental teams in tackling antibiotic resistance: 1) raising awareness about antibiotic resistance; 2) preventing dental infections; and 3) antibiotic stewardship to optimise dental antibiotic prescribing in accordance with guidelines. national dental associations are encouraged to commit to supporting international efforts to tackle antibiotic resistance and to advocate for dentistry within national action plans. the british dental association already campaigns for improved provision of urgent dental care. 31 the house of commons health and social care committee now also clearly recognises that dental procedures, not antibiotic prescriptions, are required to address the cause of dental pain and swelling. 5 aggregation and anonymisation of the datasets provided by nhsbsa means that it was not possible to determine the clinical indications/ appropriateness of the prescriptions, nor demographics of the patients who were receiving the antibiotics. data of sufficient quality for analysis or monitoring of dental antibiotic prescribing at the level of individual dental practices, clinicians or patients are not routinely collected in england at this time. during the period of increased dental restrictions owing to covid-19 (25 march-8 june 2020), all patients in england requiring urgent dental care were treated within the nhs. as practices reopened, more and more dentistry would have been provided by private providers; as data for private prescriptions are not routinely collected in england, the antibiotic figures for june and july may be under-reported compared to the figures for april and may. on 1 april 2020, nhs england reorganised its regions. as a result, it is not possible to directly compare regional rates of dental antibiotic prescribing before and after covid-19 restrictions. restricted access to dental care has resulted in increased use of antibiotics. the impact affected some regions more and for longer than others. access to dental services is an important non-clinical factor which drives unnecessary dental antibiotic prescribing. dentistry has an essential role to play in global efforts to tackle antibiotic resistance. in the words of the house of commons health and social care committee, when people present with pain or swelling, dentists must 'properly address the cause of the problem. ' as dental care provision adapts to the covid-19 era, it is important to ensure access for all to highquality urgent dental care and to understand the reasons for variation in order to optimise the use of antibiotics in the future. world health organisation. antibiotic resistance increased antibiotics use covid-19 dental preparedness letter resumption of dental services in england house of commons health and social care committee. delivering core nhs and care services during the pandemic and beyond antibiotic prescribing in uk general dental practice: a crosssectional study assessment of the appropriateness of antibiotic prescriptions for infection prophylaxis before dental procedures emergency dental care: dental clinical guidance evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal-and periapical-related dental pain and intraoral swelling: a report from the american dental association irreversible pulpitis -a source of antibiotic over-prescription? an audit of antimicrobial prescribing in an acute dental care department antimicrobial resistance: antimicrobial prescribing: the work continues antibiotic prescribing practices of filipino dentists dental antimicrobial stewardship: toolkit oral antibiotic prescribing by nhs dentists in england 2010-2017 dr1242, ir0313 and ir0318 the national archives. open government licence for public sector information clinician and patient factors influencing treatment decisions: ethnographic study of antibiotic prescribing and operative procedures in outofhours and general dental practices perceptions, attitudes and factors that influence prescribing by general dentists in australia: a qualitative study nice. antimicrobial stewardship: quality standard (qs121) prevention of infective endocarditis: guidelines from the american heart association: a guideline from the american heart association rheumatic fever, endocarditis and kawasaki disease committee, council on cardiovascular disease in the young, and the council on clinical cardiology, council on cardiovascular surgery and anaesthesia, and the quality of care and outcomes research interdisciplinary working group therapeutic guidelines: oral and dental. version 3. melbourne: therapeutic guidelines limited incidence and nature of adverse reactions to antibiotics used as endocarditis prophylaxis prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures a survey of prescribing choices of general dentists in australia antibiotic and opioid analgesic prescribing patterns of dentists in vancouver and endodontic specialists in british columbia an audit of antimicrobial prescribing by dental practitioners in the north east of england and cumbria dentists press for funded urgent time to deliver hancock's vision on antibiotics no funding was received for this study. the authors report no conflict of interest. key: cord-339147-9v3anfbo authors: nan title: correction to: oral cancer patients date: 2020-08-28 journal: br dent j doi: 10.1038/s41415-020-2087-4 sha: doc_id: 339147 cord_uid: 9v3anfbo author's correction note: letter to the editor br dent j 2020; 228: 736.the second author was inadvertently omitted from this letter. the authors were both n. al-helou and l. gartshore. sir, it is welcome news that the prime minister is taking the issue of obesity seriously. conservative dentists believe now is the time to bring dentists in from the cold, to join forces with our medical colleagues and battle obesity. obesity was a problem before the pandemic but we know now that covid-19 hits obese people disproportionately hard and that countries with high obesity rates from western europe to the us have struggled to keep people alive in intensive care units. one in four people in the uk who have died from the virus also had diabetes, and according to the latest nhs figures obesity is understood to account for 80-85% of the risk of developing the condition's type 2 incarnation. almost 30% of adults in the uk are classed as obese, which puts increased metabolic demand on one's body; more energy and oxygen are required. when a person suffers with severe obesity, their immune system works overtime and this alongside the exaggerated inflammatory response that commences 7-10 days after covid-19 symptoms first appear, is what has killed a lot of patients. obesity is a complex health issue resulting from a combination of contributing factors but numerous studies indicate an association between oral health and a variety of general health conditions including obesity and diabetes. oral health has been isolated from traditional healthcare and policy discussion, despite it being the third most expensive health condition behind diabetes and cardiovascular disease. for a lot of patients, their dentist will be the most regularly visited healthcare clinician. with their medical background, dentists, hygienists, therapists and their dental teams, who have fought a long battle against sugar, are well placed to deliver overall health messages and so reinforce the relationship between diet, excess sugar and overall health. the healthcare advice that leads to a healthy oral cavity leads to better overall health and a reduction in sugar intake underpins a stronger immune system. early interventions using a more coordinated approach between healthcare teams to tackle these related conditions would lead to more efficient resource allocation and be more effective in achieving positive health outcomes. s unfortunately, dental services for in-patients fell victim to one of the early cutbacks in nhs funding in the 1980s. it is surely time to revisit this aspect of holistic care neglected for far too long. sir, i read with great interest the paper by i. w. hashem et al. as the dental care of hospital in-patients has long been a concern of mine. 1 back in the 1970s i was employed as in-patient dental officer at guy's hospital where my duties were to look after the dental care of hospital in-patients. a large part of my work included pre-operative assessment and treatment of cardiothoracic patients and dealing with dental emergencies when they arose not just at guy's but also at the associated hospitals and care homes in the guy's group. i had a stand-alone surgery in the main hospital and a dental nurse to assist me. informal seminars were also given to nurses about the importance of the oral health of patients in their care. 2 in this time of enormous pressure on the nhs utilising the expertise of the dental team would help relieve the stresses on the hard-pressed medical and nursing staff engaged currently in their battle against covid-19 and in the long term improve patient care without adding to the burden on the already over-stretched doctors and nurses. correction to: high aerosol generating potential dental care pathways for adult inpatients in an acute hospital: a five-year service evaluation health policy: hospital cutbacks the original letter can be found online at https://doi.org/10.1038/ s41415-020-1700-x. key: cord-348947-o6qpaa6a authors: robson, j. stuart title: duty to extract date: 2020-10-23 journal: br dent j doi: 10.1038/s41415-020-2282-3 sha: doc_id: 348947 cord_uid: o6qpaa6a nan sir, as a past president of the bda i am dismayed and bemused to read frequent reports in national newspapers decrying the number of children awaiting many months for tooth extractions in hospitals. indeed, the daily telegraph claims that this is the most frequent referral cause for children to hospital, numbering equating to 177 cases per day nationally at an estimated cost of £41 million. a further report of this problem appears in the recent bdj (potential surge in post-covid child tooth extractions; bdj 2020; 229: 278). is this because dentists, both in practices and community dental services, are either unwilling or unable to perform this treatment? furthermore, it seems that frequent courses of antibiotics are prescribed to keep infection from carious teeth at bay pending hospital extraction. as we are all too aware, this repeat prescribing is undesirable, building up unnecessary resistances. i presume dental schools still educate undergraduates in the expert technique of extractions, therefore one must conclude that the problem is due to an unwillingness of clinicians in primary care to undertake these treatments. we must remember that for every child suffering from painful teeth, there are parents having to cope with stressful situations. many years ago, i was a member of the then termed 'poswillo' working party, reporting to the department of health on the safety of administering general anaesthetics (ga) in practices, but additionally our role included reviewing other means of anaesthesia. whilst not advocating a return to providing gas in outpatient clinics, in a primary care setting it is perfectly possible and permissible to extract offending teeth using either sedation or local anaesthesia or a combination of both. as healthcare professionals, dentists have a duty to relieve pain and to prevent the risk of complications arising from long-term infections rather than referring patients to a seemingly endless waiting list, especially during these difficult covid-19 times, which is exacerbating this dire state of affairs. j. stuart robson, york, uk https://doi.org/10.1038/s41415-020-2282-3 used a purpose built protection box during aerosol generating procedures (https://www. facebook.com/dentistsatwork). these solutions may not be perfect but they can provide necessary protection in the best and quickest way possible in the face of exponential spread of the pandemic and economic limitations. m. javed, qassim, saudi arabia, y. bhatti, london, uk sir, in the current pandemic, the lack of equitable oral healthcare facilities, shortfall of dental healthcare providers, shortages of equipment/materials, and inadequate management of existing services is well known in developing countries. 1 it may not be possible for such countries to upgrade the dental surgeries in their tertiary care facilities to the suggested level of ventilation, filtration, and negative pressure, due to financial limitations. the alternative solution for resource constrained environments is to explore frugal innovation approaches to make the most of existing assets and skills. 2, 3 for instance, for creating a temporary negative pressure in dental surgeries strong exhaust fans have been connected to the simple duct system to deliver the air from the surgery at the minimum three metres above the roof. 4 to prevent the transmission of infection through aerosol in the dental setting the 'protection box' is an innovative and economical solution for performing aerosol generating procedures. 5 the protection box has excellent visibility and can be reused after disinfection. recently, in pakistan a dental surgeon has designed and sir, i would like to thank all my colleagues who have worked so diligently to up-skill and kindly help guide others through the current covid-19 pandemic. until six months ago, like many colleagues, i had little knowledge of this new respiratory virus and its impact on the dental profession. thanks to this new novel virus, we now have a growing number of colleagues within dentistry who understand much more about respiratory viruses than i ever seem to remember learning at dental school or during my postgraduate studies. if we add to this the long list of acronyms with sops, agps, non-agps, ffps, written and re-written sops, the latest technology to help oral health care systems in developing and developed countries fast and frugal innovations in response to the covid19 pandemic frugal and reverse innovation in surgery frugal solutions for the operating room during the covid-19 pandemic patients' case scenario as well as approaches and strategies adopted to manage covid-19 pandemic at aligarh muslim university letters to the editor send your letters to the editor, british dental journal, 64 wimpole street, london, w1g 8ys. email bdj@bda.org. priority will be given to letters less than 500 words long. authors must sign the letter, which may be edited for reasons of space. key: cord-280944-uphs5gvl authors: stagnell, s.; moore, r. title: covid and consent date: 2020-07-10 journal: br dent j doi: 10.1038/s41415-020-1903-1 sha: doc_id: 280944 cord_uid: uphs5gvl nan sir, current guidance from the rcs recommendations for paediatric dentistry during the covid-19 pandemic is very clear: ' access to general anaesthesia will be significantly reduced for the foreseeable future' . 1 as a foundation dentist, i have had little exposure to silver diamine fluoride (sdf) during my undergraduate studies and so was very interested by the recent bdj paper highlighting its use in the management of dental caries. 2 through the utilisation of careful non-agp application methods, it can prevent the progression of carious lesions and arrest them entirely although the most immediate issue is that it is currently not licensed to be used as a caries-arresting agent in the uk. sdf has huge potential within community dentistry and general dental practices, more so at this unprecedented time. this would be particularly useful in coping with the reduced ga access and managing extensive carious lesions atraumatically, particularly in uncooperative patients. considering all of the benefits, it begs the following questions -why is it still unlicensed as a caries-arresting agent in the uk? where is the official guidance on its use? and finally, why has it not become a prevalent form of treatment considering its efficacy and appropriateness in the current climate? a. remtulla, bedford, uk references 1. royal college of surgeons of england. recommendations for paediatric dentistry during the covid-19 pandemic. 2020. available at: https:// www.rcseng.ac.uk/-/media/files/rcs/fds/guidelines/ paediatric-dentistry-covid19.pdf (accessed june 2020). 2. greenwall-cohen j, greenwall l, barry s. silver diamine fluoride -an overview of the literature and current sir, prior to the covid-19 pandemic, patients undergoing invasive procedures were subject to confirming their consent through written means, a process which is considered common within surgical fields. 1 the guidance issued by the fgdp on 1 june suggested a move towards provision of 'digital packs' and it seems many standard operating procedures (sops) being issued by practices include the provision of digital information packs with consent forms to patients. 2 patients being issued consent forms to complete on their own may require additional support in order to ensure their validity so that consent is maintained and not overlooked, in light of the new working protocols the profession faces. furthermore, in cases where patients are being triaged remotely, a complete exam may not be possible prior to execution of treatment: a key difference which has to be considered when exploring the options for consultation and delivery of clinical information. 3 there is a risk due to patients' comprehension of the intended procedure and the lack of opportunity to fully appreciate or discuss the risks and benefits. additionally, the change from a face-to-face consultation and 'cooling-off ' period, as is the case with the gold-standard two stage consent, is likely to be affected. there is also a risk of clinicians not engaging with such measures which could be viewed as a noncompliant attitude to sops and guidelines, which although essential to good practice have come to be a burden to many. sir, the covid-19 pandemic has seen the drawback of much needed pharmacological behaviour management services (ie iv sedation, ihs and ga). in experiencing such difficulties in the udc hubs, i have become a huge proponent of the often underused and overlooked use of oral sedation techniques in the management of dentally anxious patients who have previously relied on ihs or iv sedation. via anecdotal feedback, many patients are realising that they would be content to accept future treatment under such measures. with dental practices now resuming a limited level of practice and possibly experiencing the level of frustrations with lack of treatment provisions for anxious patients, oral sedation with diazepam is an invaluable tool in enabling patients the access to care they require. increasing confidence in the use of diazepam pre-medication is paramount for the changing face of dentistry, especially for those of us who have, in the past, become overly reliant on the ga, especially in polypharmacy patients. careful case selection is of course key to its successful use, and requires the triaging clinician to be thorough in ascertaining dental history and indication of sedation need. appropriate prescription of diazepam prior to attendance for urgent dental care can create positive outcomes for both the patient and treating clinician and just may result in a cultural shift that reduces the burden on sedation services when normal service resumes. g. atkinson, salford, uk https://doi.org/10.1038/s41415-020-1906-y sir, dental/rubber dam has always been a strange issue in dental practice. those of us who use it 'swear by it' , but those who don't, decry its use, often in most strident terms. there is absolutely no doubt that one of the major advantages of using it is the reduction in bacterial (viral) aerosol. given the difficult and troubled time we now work under we must assume that dental dam could be a life saver, and it would seem to be professionally   4 british dental journal | volume 229 no. 1 | july 10 2020 upfront implications of covid-19 for the safe management of general dental practice -a practical guide key: cord-032703-wxlr7p1u authors: zaki, a. a. title: photos please date: 2020-09-25 journal: br dent j doi: 10.1038/s41415-020-2186-2 sha: doc_id: 32703 cord_uid: wxlr7p1u nan in conclusion, clinical photos should become a standard part of the initial referral. most referrers (gps or gdps) have access to a camera and with the implementation of e-referral systems across most uk trusts, uncomplicated image acquisition and uploading should become standard. this is even more vital in this unprecedented time due to the risk posed by covid-19 and will ultimately grant clinicians the ability to triage more effectively, improve patients' standard of care and prevent suspected cancer lesions being missed. dental records sir, photography can be used to accurately record the appearance of the oral cavity as well as following specific clinical conditions over time. with observance to current legislation, 1 photography can facilitate diagnosis, treatment planning and surgical procedures. 1, 2 it is also useful both as a medicolegal tool and treatment goal conformational record. 3 historically artists were used to produce illustrations from the descriptions of surgeons and physicians, which were highly influenced by their interpretation. i carried out an audit to determine how often clinical photographs were present with a referral or taken at initial consultation in our department before biopsy of a suspected squamous cell or basal cell carcinoma. photos were only present in 25% of cases, yet 85% of clinicians responded that they would have benefited from one. a diagram was present in 85% of cases, but this returns us to the same difficulty of subjectivity that was present in the late nineteenth century where the artist's illustration was influenced by the interpretation of the clinician. sir, you recently published an interesting research article regarding the career aspirations of female dental students and trainees. 1 it is well documented that there are increasing numbers of females entering the profession but this study further showed that more young female dentists are considering specialties that were traditionally male dominated. however, leadership positions are still disproportionately filled by males. this highlights the need for more female role models and mentors to be present in these positions. it is also important that dental institutions play an increasing role in educating their students regarding the career options available to them, including those that may allow them to continue working or continue specialty training pathways whilst affording them the flexibility that they may want. the results from this study showed that 63% of respondents, of which 70% were females, wanted to work part-time 15 years post-qualification. this decision may play a role in hindering their progression to more senior roles. therefore, there should be provisions in place to improve chances of career progression for those working part-time. the decisions regarding an individual's career flexibility are personal and sir, many clinical signs and syndromes in medicine are named eponymously after the person who supposedly originally described them. in dentistry a common example is sjögren syndrome. these eponyms can be stated in the possessive, ie sjögren's syndrome or nonpossessive, ie sjögren syndrome. whilst this distinction may appear overly pedantic it does have importance and has been debated since the 1970s. possessive eponyms have been argued as incorrect since the discoverers generally neither had nor owned the disorders, and having the two forms can generate confusion and problems with databases and literature searches. 1 the world health organisation actively discourages use of eponymous terms in medicine. 2 furthermore, along with other bodies such as the american medical association and us national institutes of health, they specifically advocate that the possessive form is not used. however, there is no overall consensus, particularly among editors of medical journals where both forms continue. for example, in this journal's ten most recent papers mentioning the above example, seven state sjögren's, two sjögren and one uses both terms. use of the possessive is now much less common in american than european journals. 3 therefore the current state of affairs is of mixed and arbitrary usage of possessive and non-possessive forms of eponyms throughout medicine. the main practical implication here, beyond being merely a technical point, is that literature searches using either form will yield different results. 1 standardisation could solve this, however, is acknowledged dental core training: the trainee perspective situational judgement tests in medical education and training: research, theory and practice: amee guide no. 100 situational judgment test as an additional references 1. uk government. data protection the focal encyclopedia of photography office-based management of dental alveolar trauma key: cord-026765-cw4rh1on authors: dingle, m.; irshad, h.; mckernon, s.; taylor, k. title: altered exodontia techniques date: 2020-06-12 journal: br dent j doi: 10.1038/s41415-020-1726-0 sha: doc_id: 26765 cord_uid: cw4rh1on nan excipients apart from water. this has reduced the product expiration to 28 days, however this will be extended in due course as the solution is self-preserving. we have followed the s. j. challacombe et al. dosing protocols as accurately as possible (to standardise the dosing), and we anticipate the that the product will be available mid-may, initially in a 5l presentation, primarily for dentists, while a nasal and throat spray will follow in late may primarily for pre-procedural use in the hospital setting. while it cannot now be claimed that my position is unbiased, i can claim my intention from the start of this project was to find a low cost intervention to potentially break the link of patient to healthcare worker transmission. it has been very pleasing to have one's research intention and findings validated by s. j. challacombe et al., amongst others, and it is these validations that have motivated and enabled the speedy provision of ready to use povidone iodine for dentists and for preprocedural applications in the hospital setting. j following an intensive exploration regarding the use of videne as a potential product, we came to the conclusion that it is preferential to completely avoid phenol, a component of videne, as this represents an unnecessary risk. we have therefore produced a product in partnership with a pharmacy specials nhs manufacturer, which contains no sir, we write to inform your readers about techniques for non-surgical exodontia we have adapted to at liverpool university dental hospital during the covid-19 pandemic. as part of the avoidance of aerosol generating sir, i am the chief of dentistry at a tertiary care hospital in the biggest metropolis of pakistan. the first documented case of covid-19 in our country was reported in late february at our very own hospital. as cases in our population grew the dental clinic went on an emergency only protocol and to date we have provided dental care to almost 500 patients and performed approximately over 100 dental emergency procedures. during this period we also had 11 patients who subsequently underwent covid-19 testing for various non-dental reasons; later, two patient visits were verified as confirmed covid-19 cases. whilst the average infection rate for our surgery colleagues at the hospital was 20%, the dental clinic has had zero infections amongst 60 dental staff members including faculty and residents. 1 this fortuitousness can be attributed to strict administrative and engineering controls, and provision of adequate personal protective equipment (ppe) immediately after consulting recommendations which came out from national health services and the american dental association. sir, social distancing measures are predicted to last for some time but networking and faceto-face contact have always been important in the world of dentistry. for example, picking up and trying on a pair of loupes at a trade show cannot be emulated over the internet. ideally, the exhibition industry will return to its pre-covid-19 status. yet, social distancing may well become a way of life, and in that case it will be interesting to see the effect on the future of dental events. n. axiotis, l. benson, manchester, uk https://doi.org/10.1038/s41415-020-1749-6 special attention towards ppe and initiating a respiratory programme including fit testing for all our dental staff were key elements of our success. 2 furthermore, donning and doffing measures for ppe were reinforced to all staff members; adequate training via online meetings and hands-on exercises were provided; and each staff member was asked to observe one another and provide constructive feedback to improve these procedures every day. i would also like to acknowledge the unwavering support from our leadership and department of infection control during this pandemic; the provision of an adequate supply of ppe was dynamically managed and stocked up, which went a long way towards uplifting staff morale. as there is still limited understanding of the covid-19 disease, it is important to share the learnings from our experiences to help build the evidence-base. once any new guidelines come into place we can recalibrate our responses and adjust our priorities. f. umer sir, i would like to share my thoughts and experiences on how covid-19 has affected me as a year 13 student, applying to university to study dentistry this september. unfortunately our a-level examinations have been cancelled this summer. this means that instead of receiving our final grades, determining meeting our offers for university, our results will be based on grades predicted by our teachers based on past exams and schoolwork. if we are not satisfied with our predicted grades on a-level results day, we have the option to appeal and sit alternative exams during the autumn or next year. therefore, we were advised by our schools to continue revising to complete the specification of our subjects in case the appeal process is necessary. this circumstance of a retake will probably void our current university offers. i am majorly concerned about being successfully admitted to dental school this september, having already battled through the incredibly competitive personal statement, interview process and securing my offer. my fellow students and i are experiencing a number of difficulties. we are also troubled about our early dental school career possibly being spent in lockdown instead of in university, as i understand the importance of being orientated with the introduction of the course and the onsite facilities available. this is particularly essential for first year students. sir, now that roche's sars-cov-2 antibody test has been approved by public health england, might it be reasonable for dental practice generally and sdcep in particular to take this into consideration? a patient who has tested positive could be viewed as reasonably safe for agps, with normal ppe. i do understand that we have a lot still to learn, but we need some decent working hypotheses. in the larger picture, we might be able to help roll out broader testing, take the load off our medical colleagues and help the public and especially the nhs and carers get back to work safely. this is in line with scottish government policy. 1 dental patients could also be tested on their examination appointment by the dentist; results are rapid and follow up could be quickly organised to book positive patients in for agps. dentists will need some phlebotomy training. many of us have experience in this but may need updating and being taught the specific requirements of the elecsys anti-sars-cov-2 serology test; others do not have such experience and will need a somewhat more extended course. perhaps the practicalities of such training could be investigated by nes. in scotland a mechanism for reimbursement already exists within the sdr; 3601 -taking of material for pathological examination: per course of treatment £14.00 (£11.20). this would be a good mechanism for reporting results via practitioners' services, to the wider nhs and sir, the region of madrid (population 6.6 million) is one of europe's regions most affected by covid-19 with around 60,000 cases officially reported (beginning of may). on 14 march 2020 the spanish government decreed a state of alarm under which the whole population was subjected to compulsory home confinement. a few days later, the general dental council of spain advised that due to a general shortage of ppe, practices which do not have this equipment available would immediately cease to operate, including cases involving dental emergencies. consequently, only 5% of the dental clinics remained open for urgent dental care. we present a preliminary analysis of some aspects of urgent dental care performed by a dentist in this region (17 march-3 may) who was on call 24 hours a day, six days a week, with the support of an assistant. before an appointment patients underwent a telephone interview by the dentist; none reported covid-19 symptoms nor contact with infected persons. following this protocol, patients were then seen at the practice within one hour. some 25% were treated between midnight and 6 am. the time span between the presentation of symptoms and the request for urgent consultation was usually over ten days. the majority of patients (75%) had received treatment involving only the usual medication. at all times, the dentist used appropriate ppe, minimising the use of aerosol generating procedures. total patients seen were 187 (98 women; 89 men; aged 20 months-87 years). seven were children under the age of 12 and 12 were over 75. the most common diagnosis (50%) was acute periapical periodontitis, with associated abscess (19% of cases), irreversible pulpitis (13%), complications of third molar pericoronitis (7%), periodontal abscesses procedures (agps) we have been avoiding the use of a surgical handpiece where possible, removing bone with rongeurs, bone chisel/ osteotome (with a mallet) and bone files and using chisels to divide teeth (with a mallet). 1 the importance of a good pre-operative clinical and radiographic assessment as well as fully informing the patient of potential treatment and risks involved is essential. these older techniques are useful to avoid additional ppe issues and environmental issues associated with agps. m. dingle, h. irshad, s. mckernon, k. taylor, liverpool, uk change in surgical practice amidst covid 19; example from a tertiary care centre in pakistan role of respirators in controlling the spread of novel coronavirus (covid-19) among dental health care providers: a review coronavirus covid-19 impacts to dentistry and potential salivary diagnosis key: cord-299999-jra1yu6a authors: tattar, r.; roudsari, r. v. title: covid pdps date: 2020-05-22 journal: br dent j doi: 10.1038/s41415-020-1696-2 sha: doc_id: 299999 cord_uid: jra1yu6a nan this route can facilitate transmission via fomites in the surrounding environment, in much the same way as indirect respiratory droplet transmission. where toothbrushes are placed in close proximity to a toilet, there may be a heightened risk of harbouring sars-cov-2 from infected individuals. that families often house toothbrushes together, the risk of infecting other individuals could be made easier. rightly, the dental profession have reason to fear the aerosol generation from dental handpieces, particularly when the inversesquare law is applied to project the extent of dispersal. in a mechanistically similar way, toilet plumes may pose a similar challenge. professor addy offered reason to reinforce the role of toothbrushing with toothpaste, given the antimicrobial properties of toothpaste ingredients. 3 awareness and advice to limit toothbrush contamination might prove beneficial. though the evidence base is yet to be established, no harm exists in recommending this as a precautionary measure in the preventive approach to covid-19. j. patel, leeds, uk trainees approaching the end of the pathway across all specialities. all resources should and will be directed into ensuring facilities and measures to protect the safety and wellbeing of patients. however, a structure needs to be developed to account for the disruption in training covid-19 has caused and facilitate the progression of the trainees without compromising the quality and integrity of the respected specialities. m. shaath, manchester, uk https://doi.org/10.1038/s41415-020-1697-1 sir, the established modes of sars-cov-2 transmission may be an incomplete picture. in their most recent scientific brief, the world health organisation acknowledge the evidence to support contact and respiratory droplet transmission of sars-cov-2. accordingly, much of the government's infection prevention and control guidance for covid-19 is centred around minimising transmission via these methods. the coronaviruses implicated in the previous sars and mers outbreaks caused enteric manifestations in conjunction with the respiratory symptoms experienced by many with covid-19. since the early retrospective cohort studies of patients in wuhan, more recent observational studies report common gastrointestinal symptoms to be more prevalent than previously thought. 1 sars-cov and mers-cov rna were frequently detected in stool specimens of infected individuals. the new england journal of medicine case report of the first covid-19 patient in the usa detected high sars-cov-2 viral load in their stool sample. 2 experts recognise the hypothesised faecal-oral route to be a plausible mode of transmission. sir, amid the many current uncertainties dental practitioners have, trainees also have an additional worry regarding their training and how this will impact them in the future. the bearing covid-19 has had on clinical activity means that many patients being treated and prepared for cases will be delayed, target case numbers and important clinical exposure will reduce, negatively impacting trainees' progression. additionally, redeployment into other areas of the trust to aid with the response to covid-19 may divert trainees' attention from their own speciality. with royal colleges already cancelling and postponing courses and exams, this adds the stress on sir, the covid-19 pandemic has caused significant disruptions in dental services including both undergraduate and postgraduate dental training. newly qualified dentists who commenced dental foundation training in september 2019 would have only had seven months of clinical practice before the lockdown resulted in cessation of routine dentistry in the uk. 1 there are likely to be outstanding competencies and the loss of clinical experience and mentoring will need to be identified and fulfilled through a personal development plan (pdp). the enhanced continuing professional development (cpd) scheme was introduced by the general dental council (gdc) on 1 january 2018 for dentists. 2 this involves completion of the prerequisite 100 hours of cpd per cycle but also in ensuring that this is tailored to meet individual pdps to make sure maximum benefit is gained and to encourage reflective practice. at present, pdps are not a routine part of the undergraduate curricula 3 and as such, newly qualified dentists will be faced with the new challenge of having to proactively plan their cpd to fulfil outstanding competencies from their current training course. this is also likely to be the case for dentists in dental core training, speciality training and those undertaking formal postgraduate qualifications. gdc standards allow pdps to be completed individually or in conjunction with peers including employers. 2 dentists in training should seek advice from their educational supervisors and postgraduate deaneries by identifying areas within their professional activities where further training is needed, identify suitable courses   and ensure their objectives are achievable within a set timeframe. whilst cpd cycles are five years, the need to complete certain key foundation skills to ensure adequate competence and baseline knowledge to facilitate progression through postgraduate training pathways will result in trainees having to meet such objectives sooner. this will likely need to be achieved in liaison with their next training scheme. there are multitudes of factors to think about during this covid-19 pandemic and the personal development plan may be easily and understandably missed, however, its importance should not be underestimated. early planning will help trainees of all levels overcome the challenges of disruptions and mitigate adverse effects on their training progression. dilemmas arise in terms of delaying or proceeding with surgery. further useful information can be found at https:// globalsurg.org and https://www.rcseng.ac.uk/ coronavirus/rcs-covid-research-group/. we admire the epic efforts of our surgical and maxillofacial colleagues in juggling these competing demands in the best interests of the population. what can bdj readers do to help? we can make at-risk patients we triage, and patients who access our practice websites, aware of the mouth cancer foundation symptom checker (www.mouthcancerfoundation. org). 4 video consultation also offers a solution and practice websites and social media threads can include oral health advice. national smile month started on 18 may offering digital engagement (www. nationalsmilemonth.org/). mouth cancer action month is in november; the infamous #bluelipselfie might help raise awareness (www.bluelipselfie.co.uk/). we can continue to signpost smoking cessation advice online too -perhaps this new remote practice offers an opportunity to support patients who are interested in quitting smoking and the smokefree service allows patient to access advice and support from experts: quitnow. smokefree.nhs.uk/. we need to remember those patients who have previously received a cancer diagnosis who would usually be accessing our care to receive support and preventive dental care. many charities such as the throat cancer foundation and the mouth cancer foundation are continuing to provide support to affected patients (www.throatcancerfoundation.org, mouthcancerfoundation.org/). the primary care dental team has an important role in raising awareness and trying to mitigate where possible a post-pandemic spike in oral cancers with poor prognoses. n. al-helou, liverpool, uk sir, at the time of writing, uk wide guidance for surgical prioritisation during this pandemic indicates that resection of low-grade salivary gland tumours can be delayed for up to three months; oropharyngeal, tonsillar and tongue cancer resection and reconstruction for up to four weeks; post-cancer facial reconstruction for at least three months. 1 consequently, cancers diagnosed may necessarily be subject to a delay in treatment with likely adverse impact on patient outcomes. furthermore, many patients who undergo resection of oral cancer require post-operative intensive treatment unit (itu) beds. 2 with approximately 8,000 more hospital deaths to date in 2020 than is routine, elective surgery poses stress on a healthcare system already experiencing unprecedented pressures in itu, and perhaps, a redeployed staff. 3 sir, in relation to redeployment we write to encourage individuals to consider the full range of skills at their disposal during this crisis, particularly in support of areas that do not involve direct patient care, such as research. research and innovation departments around the uk are cooperating at unprecedented speed and scale to deliver covid-19 related projects, such as isaric 1 and the recovery 2 trial. dentists are well placed to fulfil roles in research teams, for example, making use of excellent communication skills or applying expertise in consent to complex circumstances. other non-patient-facing roles such as applying clinical knowledge to eligibility screening, sir, i write further to the letter by holmes et al. 1 with regard to management of broken jaws in the wake of the covid pandemic using closed reduction protocols such as intermaxillary fixation with the postoperative follow up of patients by gdps. i would, respectfully, like to add that as far as facial trauma is concerned we are fortunate to have a generous evidence base. in certain situations such as uncontrollable haemorrhage, infected injuries posing a threat for further spread, orbital trauma with progressively reduced visual acuity and any injury posing a threat to the airway must and should be addressed. 2 also, while we might be deferring cases to be dealt with at a later date, the patient should, at this very stage be counselled regarding any functional impairment which might be experienced in due course of time and a possibility of performing deformity correction at a later date. vaibhav sahni, new delhi, india high prevalence of concurrent gastrointestinal manifestations in patients with sars-cov-2: early experience from california first case of 2019 novel coronavirus in the united states toothbrushing against coronavirus urgent dental care for patients during the covid-19 pandemic standards for education standards and requirements for providers 2015 clinical guide to surgical prioritisation during the coronavirus pandemic management of post-operative maxillofacial oncology patients without the routine use of an intensive care unit comparison of weekly death occurrences in england and wales: up to week ending 10 mouth cancer foundation. symptoms. 2020. available at broken jaws in the covid era approaches to the management of patients in oral and maxillofacial surgery during covid-19 pandemic key: cord-302379-jh6jxwyn authors: jevon, phil; abdelrahman, ahmed; pigadas, nick title: management of odontogenic infections and sepsis: an update date: 2020-09-25 journal: br dent j doi: 10.1038/s41415-020-2114-5 sha: doc_id: 302379 cord_uid: jh6jxwyn the management of odontogenic infections has improved over recent decades, but further improvements are still required. the ongoing education of gdps and their dental teams on this issue continues to be important, especially during the current covid-19 pandemic, where remote triage poses additional difficulties and challenges. odontogenic infections can lead to sepsis, a potentially life-threatening condition caused by the body's immune system responding in an abnormal way. this can lead to tissue damage, organ failure and death. a patient with non-odontogenic-related infection could also present with sepsis at a dental practice. early recognition and prompt management of sepsis improves outcomes. gdps and their dental teams should be trained in the recognition and management of sepsis. age-specific sepsis decision support tools have been developed by the uk sepsis trust to help dental staff recognise and manage patients with suspected sepsis. the aim of this article is to provide an update on the management of odontogenic infections and sepsis. although the management of odontogenic infections has improved over recent decades, further improvements are needed and the ongoing education of gdps and their dental teams on this issue is essential. in addition, the covid-19 pandemic has imposed new difficulties and challenges; for example, telephone triage and prescription of antibiotics, and it is important to be up-to-date with current guidelines. 1, 2 odontogenic infections can lead to sepsis, 3,4 a potentially life-threatening condition caused by the body's immune system responding abnormally. this can lead to tissue damage, organ failure and death. 5 a patient with nonodontogenic-related infection could also present with sepsis at a dental practice. early recognition and prompt effective treatment of sepsis improves outcomes. 5 the dental team should be trained in the principles of the management of sepsis. 6 agespecific sepsis decision support tools have been developed by the uk sepsis trust 7 to assist the dental team to recognise and manage patients with suspected sepsis. the aim of this article is to provide an update on the management of odontogenic infections and sepsis in the dental practice. the morbidity and mortality rate of odontogenic infections has dropped significantly over the past 70 years. 8, 9, 10 this dramatic drop is undoubtedly linked to the discovery of antibiotics, the improvement of the general population health standards, and a better understanding of appropriate medical and surgical management of these cases. further improvements are needed and ongoing education of the dental team on this issue is very important. odontogenic infections pass through three key stages: 11 • stage 1: 1-3 days; soft and mildly tender swelling • stage 2: 2-5 days; hard, red and severely sore swelling • stage 3: 5-7 days; abscess formation. there is a strong belief that once the abscess has formed, surgical drainage is mandatory to achieve resolution. 12 medical management has a role in selected cases. 13 seven principles have been proposed to achieve the best outcome in managing odontogenic infections: 11 1. establish the severity of the infection 2. assess host defences 3. elect the setting of care 4. surgical intervention 5. medical support 6. antibiotic therapy 7. frequently evaluate the patient. a careful history and thorough clinical examinations are essential to determine the severity of any infection. history-taking will highlight factors like immune system competence and the level of systemic reserves to fight infections. a physical examination can identify clinical observations outside normal limits. several clinical and haematological parameters have been used as prognostic indicators for the severity of the infection. c-reactive protein (crp), fever and anatomical locations have been investigated for the assessment of the extent of odontogenic infections and presumed duration of hospital stay. 14 additional factors must be considered to establish the infection severity: • anatomical location • airway compromise. there are a number of potential spaces between the musculoskeletal head and neck structures and the regional fasciae and organs better known as fascial spaces. a summary of these spaces and their level of risk 11, 12 is found in table 1 . in healthy and systemically well patients without trismus, infections of low-risk spaces can be initially treated in a primary care dental practice, while infections spreading to higher risk spaces should be managed more aggressively and may need to be treated in a secondary care centre. ludwig's angina was described by karl friedrich wilhelm von ludwig in 1836 as a rapidly and frequently fatal progressive gangrenous cellulitis and ooedema of the soft tissues of the neck and floor of the mouth. 15 thankfully, mortality rates have reduced significantly with the introduction of antibiotics, improved oral and dental hygiene, and timely surgical intervention. 15 the majority of ludwig's angina infections are odontogenic; 16 peritonsillar or parapharyngeal abscesses, mandibular fractures, oral lacerations/piercing and submandibular sialoadenitis are other recognised causes. 15 a compromised airway is synonymous with ludwig's angina and the initial assessment of a patient with ludwig's angina should follow the familiar 'airway, breathing, circulation, disability, exposure' (abcde) approach. signs of a compromised airway in these patients could include noisy (gurgling) breathing with drooling saliva, stridor, dyspnoea, tachypnoea, tachycardia, dysphagia and trismus. the initial immediate management usually includes positioning the patient in an upright position and administering oxygen 15 litres/minute, 15 while colleagues call 999 for an ambulance. a healthy immune system is essential to the maintenance of host defence against infection. multiple medical conditions can affect it. 17 box 1 summarises the common factors that can cause immune system compromise. the concept of 'physiologic reserve' represents a significant driver of outcome in patients fighting infection. this can be defined as the capability of an organ to carry out its activity under stress. 18 age is an essential factor that is inversely related to the physiologic reserve; that is, decreased respiratory, cardiovascular and metabolic reserve. 19 elect the setting of care an uncomplicated localised dental abscess in a healthy young person, who does not show signs and symptoms of a worsening immune response, can be safely treated in a dental practice. early and adequate intervention is essential in order to prevent avoidable deterioration with invasion of adjusted anatomical spaces and symptoms of sepsis ( fig. 1) . similarly, severe neck infection in an immunocompromised elderly person warrants treatment in a secondary care setting. the clinical decision to choose the setting of care is not always straightforward though, prompting the need for clear secondary care referral criteria. although there are no agreed national guidelines on when to admit to a secondary care setting, criteria for hospital admission have been proposed 2,20 (box 2). a careful history, thorough clinical examinations and a high index of suspicion will enable the gdp to diagnose and appropriately manage patients presenting with odontogenic sepsis. early surgical intervention has been advocated to improve the clinical outcome of odontogenic infection. the dramatic improvement in the outcome of sever odontogenic infection is directly linked to the immediate establishment of a safe airway, followed by early surgical intervention. once the airway has been deemed patent and not at risk of being compromised, in either a hospital setting or dental practice, the principles of management are very similar. thorough knowledge of head and neck anatomy will enable the surgeon to access the abscess cavities using incisions in safe places without damaging any vital structures like blood vessels or nerves. most of the odontogenic infections can be drained through intraoral access. five principles must be followed: 11 21 although abscess formation takes place between the fifth and seventh days, early elimination of the infection source and surgical intervention will decompress the involved anatomical spaces. 14 relying on antibiotics only in relieving dental infection is likely to be less effective and can cause antimicrobial resistance. 22 two of the challenges to performing adequate drainage of any odontogenic infection in dental practice are: 23 1. achieving adequate local anaesthesia 2. risk of spreading the infection to other anatomical spaces. the ability to deliver safe, adequate local anaesthesia is essential for any dental procedure. the mechanism of action of the local anaesthetic solution depends on the tissue ph. in the presence of infection, tissue ph becomes more acidic, which slows down the degree of ionisation, resulting in less optimal or failed anaesthesia. 23 to overcome this problem, the injection of the anaesthetic solution at a distance from the inflammatory site is required (nerve blocks). it will also avoid infection spread to different tissue spaces. although surgical drainage is the classic approach to most of the odontogenic infection, medical support has a critical role in controlling the disease. 24 adequate hydration, nutrition and control of fever are essential to optimise the medical care for patients presenting with odontogenic infections. stabilisation of any underlying systemic disease (for example, uncontrolled diabetes) is extremely important. 24 box 2 criteria for referral to secondary care 2, 20 • difficulty in swallowing and dehydration first-line antibiotics for dental abscess in dental practices (adults and children more than 12 years) odontogenic infections are multi-microbial with a combination of facultative and anaerobes species. facultative streptococcus viridans group are commensal gram-positive bacteria and include s. anginosus, s. intermedius and s. constellatus. these organisms are abundant in the mouth and most frequently associated with orofacial cellulitis and abscess. after a few days, the anaerobes (prevotella and porphyromonas) predominate. the majority of the facultative streptococci that cause odontogenic infections are sensitive to penicillin. 25 approximately a quarter of strains of prevotella and porphyromonas are penicillin-resistant. 26 the scottish dental clinical effectiveness programme (sdcep) has published evidencebased guidance on antibiotic prescription in dental practice. penicillin-based antibiotics remain the first line for the treatment of odontogenic infections. metronidazole is effective against anaerobic bacteria. 1, 27, 28 the antibiotic doses recommended in the sdcep's guidance are based on the doses recommended by the british national formulary (bnf) 13 (table 2 ). in secondary care settings, the antibiotics are prescribed in accordance with the local hospital antimicrobial therapy. consultation with the on-call microbiologist is a common practice for severe cases and cases which are not responding to first-line treatment. the last principle, but as vital as the previous ones, is the periodic re-evaluation of these patients. in outpatient settings, the recommended follow-up is after two days. 29 forty-eight hours will allow the drainage to cease and the immune system to overcome the initial insult from the infection. if no improvement or deterioration of symptoms is noted, further escalation in care must be provided. the review interval, however, depends on the clinical course of the infection. a patient with a rapidly developing swelling and mild temperature may need review within 24 hours, but a patient with a chronic abscess and no systemic symptoms will need to be reviewed at the end of the antibiotic treatment. causes of treatment failure include: • failure to remove the source of infection • underlying systemic disease; for example, uncontrolled diabetes • antibiotic-related factors -patient non-compliance, drug not reaching site secondary to inadequate drainage, wrong antibiotic choice or incorrect dose. in hospital settings, more frequent evaluations are essential as the disease is expected to be more aggressive. the covid-19 pandemic has dramatically changed dental practice since march 2020. guidance on the management of acute dental problems is available. 2, 30 this is likely to change as the situation evolves. advice, analgesia and antimicrobials (when indicated) should form the basis of primary care dental triage when using remote consultation (telephone call or video call). 1 while assessing the patient, covid-19 status should be established and documented, as this will determine how the patient's care will be managed should referral to an urgent dental care centre or secondary care be required. patients should be advised that dental treatment options are currently severely restricted and that they should call back in 48-72 hours if their symptoms have not resolved. 2 the sdcep's flowchart (fig. 2) helps the remote management of patients by guiding the gdp to categorise the patient into one of three management groups. 2 the sdcep has also recently updated their drugs for the management of dental problems worryingly, there has been a rise in anecdotal reports of antibiotics apparently being overprescribed for dental pain since the outbreak of covid-19. 31 this pandemic has demonstrated the havoc a pathogen can unleash when we have no protection against it. inappropriate use of antibiotics increases the likelihood that resistant bacteria will evolve 31 and it is essential that gdps remain guardians against antimicrobial resistance. 1,32 antibiotics should only be prescribed if it is likely that the patient has a bacterial infection, and the principles of prescribing and follow-up (as detailed earlier) should be followed. it is estimated that 234,000 patients develop sepsis in the uk every year, 5 with 70% of sepsis cases originating in the primary care setting. annually, there are approximately 44,000 deaths from sepsis in the uk 5 and six million deaths worldwide. 33 although deaths from sepsis due to odontogenic infection are very rare, they have been reported. 34 the incidence of sepsis is on the increase, possibly due to: 35 • a growing elderly population • an increased use of invasive surgery • an increased incidence of bacterial resistance • an increased number of immunocompromised patients. a localised infection which progresses into an uncontrolled systemic response is usually the cause of sepsis. progression to acute physiological deterioration with the risk of multiple organ failure and death can be swift. • pneumonia: 50% • urinary tract: 20% • abdomen: 15% • skin, soft tissue, bone and joint: 10% • endocarditis: 1% • device-related infection: 1% • meningitis: 1% • others: 2%. in normal circumstances, the body's immune system will prevent or fight infection (bacteria, viruses, fungi). however, the immune system can sometimes go into overdrive, resulting in vital organs and other tissues being targeted. this can result from any injury or infection in the body. although a wide variety of different microorganisms (for example, streptococcus, e. coli, mrsa or clostridium difficile) can cause sepsis, it is usually caused by common bacteria that don't normally make patients ill. 36 any infection can lead to sepsis (box 3), though pneumonia (commonly referred to as chest sepsis) is the cause in half of the cases. 5 the national institute for health and care excellence (nice) 6 the uk sepsis trust has developed age-specific sepsis decision support tools to assist the dental team to assess both adult and paediatric patients who may have sepsis. 7 utilisation of these sepsis decision tools will help determine if red flag sepsis (see below) is present, prompting appropriate timely action. the prompt transfer of patients presenting with orofacial infections suspected of sepsis to an acute hospital setting for early treatment should ultimately improve sepsis survival rates. 37 the care quality commission (cqc) 38 endorses these sepsis decision tools and, ideally, all three should be readily available in the dental practice. the 'gdp sepsis decision support tool for primary dental care' (fig. 3) should be applied to all adults and young people aged 12 years and over with fever (or recent fever), symptoms presenting with a source of orofacial/dental infection (including post-operative infection) or have clinical observations outside normal limits. 7 it details what to look out for if the patient has presumed infection and, in particular, what constitutes red flag sepsis. red flag sepsis is a definition from the uk sepsis trust which lists a set of easyto-assess clinical parameters, the presence of one of which in the context of infection identifies sepsis with a high risk of death and a requirement for urgent treatment (fig. 3) . 7 if red flag sepsis is present: there are two paediatric sepsis decision tools, one for children aged 5-11 years (fig. 4) and one for children <5 years (fig. 5) . these should be used in children who have a suspected source of orofacial/dental infection (including post-operative infection) or have clinical observations outside the normal range. 7 the paediatric sepsis decision tools take into account paediatric considerations, including differences in paediatric physiology. covid-19 infection can cause sepsis on its own. 5 unfortunately, the sepsis signs and symptoms for a number of initial conditions can be very similar. this stresses the importance for dental teams to be familiar with sepsis and the decision tools described here for safe management of such patients. in addition, evidence suggests that, for a period of time following sepsis, patients may be vulnerable and develop further infections including covid-19; therefore, they have an increased risk of readmission with infective complications (including sepsis). 5 the nice advises that patients with suspected sepsis are assessed following a structured set of observations to stratify the risk of acute illness or death. 6 the royal college of physicians' national early warning score (news) 2 is widely used by the ambulance service and in hospitals, and reliably detects deterioration in adults, triggering review, treatment and escalation of care, particularly sepsis. 41 although news2 hasn't yet been validated for use in primary care, nhs england is encouraging its widespread use in this sector. 42 the cqc has created a webpage titled 'dental mythbuster 25: sepsis' on its website, 38 providing helpful information relating to the management of sepsis in the dental practice, including online links to professional guidelines (nice and uk sepsis trust) as well as what to expect from the cqc, relating to sepsis, when they review dental practices to determine whether they are safe and well-led. when reviewing dental practices, the cqc will ask dental staff what systems and processes are in place to manage a patient with a bacterial infection, including procedures for follow-up and referral for specialist care when necessary. this will include treating patients who: • are not responding to conventional oral antibiotic treatment • cannot have their infection drained at an initial appointment. the cqc will also ask what advice is given to patients, including when they should seek emergency advice or treatment, if symptoms worsen or when the dental surgery is closed. odontogenic infections can lead to sepsis, which can result in tissue damage, organ failure and death. this article has outlined the management of odontogenic infections, including the latest covid-19 guidelines. drugs for the management of dental problems during covid-19 pandemic management of acute dental problems during covid-19 pandemic severe odontogenic infections with septic progress -a constant and increasing challenge: a retrospective analysis medical emergencies: sepsis in primary dental care professional resources sepsis: recognition, diagnosis and early management nice guideline uk sepsis trust. clinical tools. 2020. available online at changing trends in deep neck abscess. a retrospective study of 110 patients deep neck abscesseschanging trends life-threatening oro-facial infections peterson's principles of oral and maxillofacial surgery deep space neck infection: principles of surgical management prescribing in dental practice increasing frequency and severity of odontogenic infection requiring hospital admission and surgical management ludwig's angina ludwig's angina management of head and neck infections in the immunocompromised patient organ reserve, excess metabolic capacity, and aging influence of aging and environment on presentation of infection in older adults criteria for admission of odontogenic infections at high risk of deep neck space infection irrigating drains for severe odontogenic infections do not improve outcome antibiotic selection in head and neck infections pharmacology of local anaesthetics used in oral surgery is conservative treatment of deep neck space infections appropriate? evaluation of bacterial spectrum of orofacial infections and their antibiotic susceptibility severe odontogenic infections. part 2. prospective outcomes study management of acute dental problems: guidance for healthcare professionals sdcep. drug prescribing for dentistry: dental clinical guidance deep neck infection covid-19 guidance and standard operating procedure when to prescribe antibiotics royal college of surgeons, faculty of general dental practice (uk) & bda. open letter on prescribing antibiotics during covid-19 assessment of global incidence and mortality of hospital-treated sepsis. current estimates and limitations death from overwhelming odontogenic sepsis: a case report sepsis guidance implementation advice for adults sepsis decision support tool for primary dental care dental mythbuster 25: sepsis resuscitation council uk. the abcde approach basic guide to medical emergencies in the dental practice: second edition news) 2: standardising the assessment of acute-illness severity in the nhs national early warning score (news) the recognition and management of sepsis in the dental practice has also been discussed, including the age-specific sepsis decision support tools developed by the uk sepsis trust. key: cord-313084-l7odplqg authors: sampson, victoria; kamona, nawar; sampson, ariane title: could there be a link between oral hygiene and the severity of sars-cov-2 infections? date: 2020-06-26 journal: br dent j doi: 10.1038/s41415-020-1747-8 sha: doc_id: 313084 cord_uid: l7odplqg on 30 january 2020, the world health organisation identified covid-19, caused by the virus sars-cov-2, to be a global emergency. the risk factors already identified for developing complications from a covid-19 infection are age, gender and comorbidities such as diabetes, hypertension, obesity and cardiovascular disease. these risk factors, however, do not account for the other 52% of deaths arising from covid-19 in often seemingly healthy individuals. this paper investigates the potential link between sars-cov-2 and bacterial load, questioning whether bacteria may play a role in bacterial superinfections and complications such as pneumonia, acute respiratory distress syndrome and sepsis. the connection between covid-19 complications and oral health and periodontal disease is also examined, as the comorbidities at highest risk of covid-19 complications also cause imbalances in the oral microbiome and increase the risk of periodontal disease. we explore the connection between high bacterial load in the mouth and post-viral complications, and how improving oral health may reduce the risk of complications from covid-19. on 31 december 2019, the world health organisation (who) was informed of a cluster of 27 cases of pneumonia with no known cause linked to a wet animal wholesale market in wuhan city, china. 1 by 7 january 2020, the causative virus was identified as sars-cov-2, which causes the disease covid-19, and was declared a global emergency by the who on 30 january 2020. zhu et al. (2020) were able to identify and characterise sars-cov-2 using unbiased sequencing samples from infected patients with pneumonia. 2 the viral genome revealed sars-cov-2 to be 75-80% identical to severe acute respiratory syndrome coronavirus (sars-cov) and several bat coronaviruses. prior to this discovery, six coronaviruses were known to cause human disease. four viruses (229e, oc43, nl63 and hku1) are prevalent and cause common cold symptoms. the two other strains are sars-cov and middle east respiratory syndrome coronavirus (mers-cov), both of which are zoonotic in origin and fatal. sars-cov-2 has joined as the seventh member of the family of coronaviruses that infect humans. 2 no specific treatment is yet accessible; however, management involves restriction of travel, patient isolation and the support of medical supervision. 3 covid-19 affects people in different ways, with patients exhibiting a range of symptoms and severity. while risk factors such as age, gender and comorbidities have been highlighted as increasing the risk of complications and mortality, there is still a high proportion of patients with no identified risk factors who suffer from severe side effects and complications. as much as 10-15% of people under 60 years old with no risk factors are exhibiting moderate to severe reactions to covid-19. 1 while covid-19 has a viral origin, it is suspected that in severe cases, bacterial superinfections may contribute to causing complications such as pneumonia and acute respiratory distress syndrome (ards). we explore the connection between high bacterial load in the mouth and postviral complications, and how improving oral health may reduce the risk of complications from covid-19. the clinical symptoms of covid-19 appear after an incubation period of approximately 5.2 days 4 and range from fever (98.6%), fatigue (69.6%), dry cough (59.4%), myalgia (34.8%) and sore throat (17.4%). 5 diarrhoea has also been shown to be a key distinguishing symptom of covid-19 compared with sars-cov and mers-cov. 6, 7 covid-19 infections can present with mild, moderate or severe illness. the severity of the illness, the rate of decline and the risk of mortality are significantly dependent on risk factors highlighted by zhou et al. (2020) in the largest retrospective cohort study among patients with covid-19. 8 these risk factors include age (the mean age was 69 years old), gender (men represented 70% of deaths) and an underlying comorbidity in 48% of cases (hypertension 30%, diabetes 19%, or heart disease 8%). in april, research from europe added obesity as a risk factor for developing complications from covid-19, with 47.6% of patients in intensive care units (icus) having a bmi over 30 kg/m 2 . 9 the main complications of severe illness are blood clots, pneumonia, sepsis, septic shock and ards. 1 it has also been discovered that, in some cases, a dysregulated immune reaction triggers overproduction of early response pro-inflammatory cytokines (tumour necrosis factor [tnf], il-6, and il-1β), resulting in a 'cytokine storm' . 10 this exposes patients to increased risk of vascular hyperpermeability and multi-organ failure, particularly to the heart and kidneys. 11,12,13 il-6 levels are shown to be comparatively higher in non-survivors than those who survive. 10 when pneumonia spreads to the lungs and blood oxygen levels fall, patients require assisted ventilation, shifting their diagnosis from pneumonia to ards. of 201 severely affected inpatients in china, 41.8% developed ards. of these, 52.4% died due to respiratory failure, making ards the primary cause of death in infected patients. 14 this is supported by a country report covering italy, showing that 96.5% of complications arising from covid-19 infection were ards, followed by acute renal failure (29.2%). 15 this suggests that patients are more likely to die from post-viral infection complications than from covid-19. ards was also the biggest cause of death for sars-cov 16 and mers-cov infections, 17 further confirming the connection between the three coronaviruses. as of 3 march 2020, covid-19 was predicted to have a 3.4% mortality rate. 5 the period from the onset of symptoms to death averages 14 days. a significant unanswered question is why some patients suffer from covid-19 more severely than others. though patients with risk factors such as age, gender and comorbidities have an increased rate of complications and mortality, there is still a high proportion of seemingly young and healthy infected patients with no identified risk factors who suffer from severe side effects and complications, while some infected patients never go on to develop anything more than anosmia. 18 it is common for respiratory viral infections to predispose patients to bacterial superinfections, leading to increased disease severity and mortality; for example, during the influenza pandemic in 1918, where the primary cause of death was not from the virus itself but from bacterial superinfections. the same was apparent in the 2009 h1n1 influenza pandemic, where again bacterial superinfections were the primary cause of death as opposed to the virus itself. 19 despite the proven importance of superinfections in the severity of respiratory disease, they are often understudied during respiratory infection outbreaks, mainly due to the fact that diagnosing a superinfection is complex. 19 other strands of the coronavirus have shown to enhance streptococcal adherence to epithelial cells along the respiratory tract, causing complications such as pneumonia 20 and inflammatory damage in the lungs that inhibit the clearance of bacteria. zheng et al. 21 compared the levels of granulocytes in patients suffering from mild covid-19 infections to those suffering from severe infections. patients suffering from severe infections had a remarkably higher neutrophil count and a significantly lower lymphocyte count than in mild patients. a high neutrophil count is abnormal for a viral infection, but very common for a bacterial infection, resulting when lymphocyte levels reduce, severity increases. this was also seen by liu et al., 22 who deduced that the neutrophil-tolymphocyte ratio predicts the severity of the patient's response to covid-19. they found that in severe cases, over 80% of patients had an exceptionally high bacterial load secondary to a bacterial superinfection and required antibiotics. this is supported by the promising research performed in france, 23 where a combination of hydroxychloroquine (antiviral) and azithromycin (antibiotic) was shown to cure 100% of patients virologically after six days, compared to patients who had hydroxychloroquine alone (57.1%) and those who had no treatment (12.5%). while the use of hydroxychloroquine has been under much dispute, it is important to understand that antibiotics clearly play an influential role in treatment outcome, improving the success rate by 42.9% in this case. a retrospective report of 1,060 patients in may 2020 confirms the efficacy of using a combination of an antibiotic with an antiviral, with 91.7% virologically cured after ten days. 24 furthermore, chen 26 illustrating the potential importance of antibiotics and therefore bacteria in the course of a covid-19 complication. 19 see figure 1 for the outcomes of different treatment options for covid-19. the lungs, similar to the oral cavity, are often referred to as an 'ecological community of commensal, symbiotic and pathogenic organisms' . 27 microbial immigration and elimination are constant between the oral cavity and the lungs, allowing for a healthy microbiotic distribution. 28 similar to the gut or the oral cavity, bacterial communities that colonise the lungs are recognised for their function in conserving tissue, immune and organ homeostasis. the lungs are unique, however, as they are oxygen-rich and therefore contain a fine equilibrium of lipidrich surfactants that influence bacteriostatic activity. this equilibrium can alter drastically during illness, allowing microbial overgrowth and injury to the lungs. lower respiratory infection is initiated by the contamination of the lower airway epithelium by inhalation of microorganisms encompassed in aerosolised droplets, or by aspiration of oral secretions associated with oral disease (containing microorganisms such as p. gingivalis, f. nucleatum, p. intermedia). 29 periodontitis and decay are the two most common oral diseases associated with an imbalance of pathological bacteria in the mouth. cytokines (such as il-1 and tnf) from periodontally diseased tissues can infiltrate the saliva through the gingival crevicular fluid and be aspirated to cause inflammation or infection within the lungs (fig. 2) . 30 therefore, inadequate oral hygiene can increase the risk of inter-bacterial exchanges between the lungs and the mouth, increasing the risk of respiratory infections and potentially post-viral bacterial complications. 31 in a nationwide population-based cohort study, 49,400 chronic periodontitis patients were treated with periodontal therapy over 11 years. the kaplan-meier plot demonstrated the total incidences of pneumonia significantly decreased over a 12-year follow-up in the group receiving periodontal therapy (p <0.001). the reduction or eradication of periodontal disease significantly reduces one's risk of pneumonia. good oral hygiene has been recognised as a means to prevent airway infections in patients, especially in those over the age of 70. 32 the oral cavity houses more than 700 bacteria, viruses and fungi that can colonise the mouth. 33 various microbiological habitats exist within the mouth; however, the primary bacterial inhabitants are p. intermedia, s. mutans, f. nucleatum and p. gingivalis. 34 several mechanisms have been proposed to explain the potential role of oral bacteria in the pathogenesis of a respiratory infection: 30 1. aspiration of oral pathogens into the lungs 2. periodontal disease-associated enzymes may modify the mucosal surfaces to allow for adhesion and colonisation of respiratory pathogens 3. periodontal disease-associated enzymes may destroy the salivary pellicles on bacteria to hinder clearance from mucosal surfaces 4. respiratory epithelium may be altered by periodontal-associated cytokines to promote infection by respiratory pathogens. 35 the bacteria in the oral biofilm are in prime position to be aspirated into the respiratory tract and help initiate or progress conditions such as pneumonia or sepsis. a high bacterial and viral load in the mouth can further complicate systemic diseases such as cardiovascular disease, cancer, neurodegenerative disease and autoimmune diseases, 36 further supporting the link between mouth and body. the established risk factors for covid-19 (age, gender and comorbidities) 8 are also heavily implicated in imbalances in the oral microbiome. diabetes, hypertension and heart disease are associated with higher numbers of f. nucleatum, p. intermedia and p. gingivalis, 37 and associated with the progression of periodontal disease. patients with periodontal disease are at a 25% increased risk of cardiovascular disease, 38, 39 triple the risk of diabetes mellitus 40 and a 20% increased risk of hypertension. 41 epithelial sensitisation and haematogenous spread of proinflammatory mediators such as cytokines, produced in the diseased periodontal tissue, can increase systemic inflammation and diminish airflow. this can be exacerbated by the stimulation of the liver to produce acute phase proteins, such as interleukin-6, which potentiate the inflammatory response of the lungs and the rest of the body. 42 similarly, patients with severe covid-19 infections also express systemic inflammation and significantly higher levels of interleukin-6, interleukin-2, interleukin-10, tnf and c-reactive protein. 43 nagaoka et al. 44 investigated the effects of periodontopathic bacteria such as f. nucleatum, p. gingivalis and p. intermedia on pneumonia, and found that p. intermedia in particular induced severe pneumonia in subjects with higher levels of periodontopathic bacteria. pneumonia and acute viral respiratory infections are two of the most common airway infections in older patients 45 and the greatest causes of death in patients over 70 years. a randomised controlled trial in japan investigated whether improved oral care reduced the incidence of pneumonia and pneumonia-related deaths. four hundred and seventeen patients were provided with oral care after every meal and compared with the control group. of the control group, 19% contracted pneumonia compared with only 11% who received oral care. moreover, the postpneumonia mortality rate in the control group was almost double that of the group prescribed oral care. 45 the link between good oral care and a reduced risk of acute viral respiratory infections has been established in a number of other studies, 30, 46, 47, 48 including a systematic review that concluded one in ten pneumoniarelated deaths in the elderly could be prevented by improving oral hygiene. 32 furthermore, improved oral care can significantly reduce the incidence of ventilator-associated pneumonia in icu patients. 49 the more severe the form of covid-19, the higher the chance of complications such as pneumonia, ards, sepsis, septic shock and death. the development, severity and risk of complications following a covid-19 infection depend on a number of host and viral factors that will affect a patient's immune response. while 80% of patients with covid-19 infections have mild symptoms, 20% progress to have a severe form of infection associated with higher levels of inflammatory markers (il-2, il-6, il-10), bacteria and neutrophil-to-lymphocyte count. we suggest that the connection between the oral microbiome and covid-19 complications should be investigated in the process of better understanding the outcomes of covid-19 disease. the four main comorbidities associated with an increased risk of complications and death from covid-19 are also associated with altered oral biofilms and periodontal disease, hence why the link between poor oral health and covid-19 complications is suggested. periodontopathic bacteria are implicated in systemic inflammation, bacteraemia, pneumonia and even death. periodontopathic bacteria is also present in the metagenome of patients severely infected with sars-cov-2, where high reads for prevotella (493 reads), staphylococcus (1,659 reads) and fusobacterium (463 reads) were discovered. 50 it is clear that bacterial superinfections are common in patients suffering from a severe case of covid-19, with more than 50% of deaths exhibiting bacterial superinfections. 19 furthermore, it is common for respiratory viruses to predispose patients to bacterial superinfections, as seen in the influenza outbreaks in 1918 and 2009. 19 over 80% of patients in icu exhibited an exceptionally high bacterial load, 22 and treatment has been successful with a dual regime of an antiviral and an antibiotic. 23 despite the proven importance of superinfections in the severity of respiratory viral diseases, they are often understudied due to the complexity of diagnosis and culturebased microbiological testing being less sensitive once antibiotics are administered. 19 more research should be performed on bacterial superinfections, and the connection, if any, between the oral microbiome and covid-19 complications are urgently required to establish the importance of oral hygiene and pre-existing oral disease in the severity and mortality risk of covid-19. meanwhile, we recommend that oral hygiene be maintained, if not improved, during a sars-cov-2 infection in order to reduce the bacterial load in the mouth and the potential risk of a bacterial superinfection. we recommend that poor oral hygiene be considered a risk to post-viral complications, particularly in patients already predisposed to altered biofilms due to diabetes, hypertension or cardiovascular disease. bacteria present in patients with severe covid-19 are associated with the oral cavity and improved oral hygiene may play a part in reducing the risk of complications. clinical management of severe acute respiratory infection when novel coronavirus (2019-ncov) infection is suspected a novel coronavirus from patients with pneumonia in china angiotensin-converting enzyme 2 (ace2) as a sarscov2 receptor: molecular mechanisms and potential therapeutic target early transmission dynamics in wuhan, china, of novel coronavirus infected pneumonia world health organisation. coronavirus disease (covid-19) pandemic. 2020 the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak covid-19 infection: implications for perioperative and critical care physicians clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospectove study high prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (sarscov2) requiring invasive mechanical ventilation the trinity of covid-19: immunity, inflammation and intervention covid-19 cytokine storm: the interplay between inflammation and coagulation should covid-19 concern nephrologists? why and to what extent? the emerging impasse of angiotensin blockade a pathological report of three covid-19 cases by minimally invasive autopsies risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease european centre for disease prevention and control. coronavirus disease 2019 (covid-19) pandemic: increased transmission in the eu/eea and the ukseventh update is sars just ards? molecular immune pathogenesis and diagnosis of covid-19 covid-19 infection: the perspectives on immune responses co-infections: potentially lethal and unexplored in covid-19 infection with human coronavirus nl63 enhances streptococcal adherence to epithelial cells functional exhaustion of antiviral lymphocytes in covid-19 patients neutrophil to lymphocyte ratio predicts critical illness patients with coronavirus disease in the early stage hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial early treatment of covid-19 patients with hydroxychloroquine and azithromycin: a retrospective analysis of 1061 cases in marseille, france clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study the italian coronavirus disease 2019 outbreak: recommendations from clinical practice influence of the lung microbiota dysbiosis in chronic obstructive pulmonary disease exacerbations: the controversial use of corticosteroid and antibiotic treatments and the role of eosinophils as a disease marker paradigms of lung microbiota functions in health and disease, particularly association of periodontal infections with atherosclerotic and pulmonary diseases role of oral bacteria in respiratory infection oral biofilms, periodontitis, and pulmonary infections a systematic review of the preventative effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomised controlled trials defining the normal bacterial flora of the oral cavity the respiratory tract microbiome and lung inflammation: a two-way street the periodontopathic bacterium fusobacterium nucleatum induced proinflammatory cytokine production by human respiratory epithelial cell lines and in the lower respiratory organs in mice can oral bacteria affect the microbiome of the gut? subgingival microflora and antibody responses against periodontal bacteria of young japanese patients with type 1 diabetes mellitus dental disease and the risk of coronary heart disease and mortality is there an association between periodontitis and hypertension? periodontitis and diabetes: a two-way relationship periodontitis is associated with hypertension: a systematic review and meta-analysis periodontitis and respiratory diseases: a systematic review with meta-analysis correlation analysis between disease severity and inflammation-related parameters in patients with covid-19 pneumonia prevotella intermedia induces severe bacteraemic pneumococcal pneumonia in mice with upregulated platelet-activating factor receptor expression oral care reduces pneumonia in older patietns in nursing homes professional oral care reduced influenza infection in elderly modifiable risk factors for nursing homeacquired pneumonia bronchopneumonia and oral health in hospitalised older patients oral care reduced incidence of ventilator associate pneumonia in icu populations metagenome of sars-cov2 patients in shenzhen with travel to wuhan shows a wide range of species -lautropia, cutibacterium, haemophilus being most abundant -and campylobacter explaining diarrhoea the authors declare no conflicts of interest related to the study. key: cord-293180-f1ulk9ce authors: li, r w k; leung, k w c; sun, f c s; samaranayake, l p title: severe acute respiratory syndrome (sars) and the gdp. part ii: implications for gdps date: 2004-08-14 journal: br dent j doi: 10.1038/sj.bdj.4811522 sha: doc_id: 293180 cord_uid: f1ulk9ce the transmission modes of sars-coronavirus appear to be through droplet spread, close contact and fomites although air borne transmission has not been ruled out. this clearly places dental personnel at risks as they work in close proximity to their patients employing droplet and aerosol generating procedures. although the principle of universal precautions is widely advocated and followed throughout the dental community, additional precautionary measures — termed standard precaution may be necessary to help control the spread of this highly contagious disease. patient assessment should include questions on recent travel to sars infected areas and, contacts of patients, fever and symptoms of respiratory infections. special management protocols and modified measures that regulate droplet and aerosol contamination in a dental setting have to be introduced and may include the reduction or avoidance of droplet/aerosol generation, the disinfection of the treatment field, application of rubber dam, pre-procedural antiseptic mouthrinse and the dilution and efficient removal of contaminated ambient air. the gag, cough or vomiting reflexes that lead to the generation of aerosols should also be prevented. in the first part of this two-part article an account of the epidemiology, virology, pathology and management of severe acute respiratory syndrome (sars) was provided together with public health issues and general aspects of infection control. in this concluding part we describe in detail the implications of sars for the general dental practitioners together with infection control guidelines that may be applied in a primary dental care setting in the event of such an outbreak. the suggested guidelines have been modulated based on the promulgations by the british and north american infection control agencies, and our own close encounters with the sars outbreak in hong kong. sars patients are unlikely to seek dental treatment in the early acute phase of the disease owing to the rapid course of the disease and the onset of fever as a primary symptom. indeed, the observation that maximum infectivity coincides roughly with the presence of high fever, when the patients would be seeking medical rather than dental care, 1 appears to be the major reason for the absence of sars infection in dental settings thus far. nonetheless, due to the highly infectious nature of the disease, and as the modes of transmission and infectivity are not fully understood, especially in the prodromal and convalescent stages of the disease dental healthcare workers maybe at risk of exposure to sars-cov. this is particularly the case as in dentistry the care provider has to operate in close proximity to the patient using droplet and aerosol generating procedures. the fact that the droplet spread mainly occurs within a 3 feet radius of the infective focus emphasizes this danger further. as discussed earlier, sars is likely to be transmitted via droplets, close contact and fomites. when an individual coughs or sneezes, or when aerosol generating procedures are used particles of varying size (from 0.001 µm to up to 10,000 µm) are produced. particles or droplets with a diameter greater than 100 µm, as most are, called splatter or spatter are then propelled through the air for short distances, generally 3 ft or less and settle rapidly on either animate or inanimate surfaces. transmission of infection via droplets thus requires close contact with an index case. on the other hand smaller droplets (or aerosols, generally under 10 µm in size) or small-particle residue of evaporated droplets are usually airborne and are entrained in the air for a lengthy period • sars is a highly infectious disease and dental personnel are likely to be at risk because of the nature of their profession, working in close proximity to the patient. • management protocol may be modified to minimise public health risks. this includes the identification, isolation, management and report of possible and probable cases and contacts. • the principles of standard precautions should be followed. • effective infection control and treatment planning should include measures aimed at minimising the generation of, or contact with infectious droplets and aerosol. • modified universal infection control recommendations (now termed standard precautions) relevant to sars is provided, based on different clinical scenarios. and, may carry infectious microbes. they may be dispersed widely by air currents and the disease transmission thus become airborne. 2 it is salutary to note that the microbe-laden aerosol may also settle in surrounding areas in the clinic/office devoid of any clinical activities. the infective dose of the organism is another important consideration that should be borne in mind when considering airborne infection. an influenza virus particle or a few spores of the aspergillus fungus may have widely differing potentials for causing respiratory infection as is the viability of the microbes and the general health of the person inhaling them. the foregoing risks to the dental professionals posed by airborne particles have been assessed and precautionary measures recommended elsewhere. 3, 4 the measures for controlling droplets and aerosols will be discussed later in this article. we describe in detail below the management protocols recommended for different clinical scenarios one may encounter in sars-affected areas: 1. possible and probable sars cases. 5 the concept of 'standard precautions' should be applied regardless of the management protocols suggested below. as is the routine, infection control measures begin with a thorough medical history questionnaire. the most recent case definition 5,6 for sars should be used for screening purposes and special emphasis should be placed on the course of events 10 days prior to the dental appointment. the health protection agency (hpa) of the uk has given guidelines 7 on patient assessment which includes a detailed travel history from patients with symptoms and a contact history with those who have had similar signs and symptoms of sars. specifically, the patient should also be asked, or temperature taken as the case may be, if he or she is running a fever (> 38 ºc) or suffering from flu-like symptoms, myalgia, unproductive cough or diarrhoea. once a sars case is suspected, the dentist must immediately inform the health authorities. in the unlikely event of a sars patient, in the early phase of the disease, attending for a dental appointment priority should be given to minimising disease transmission. the patient should be immediately provided with a surgical mask and transferred to a secluded private area away from other patients or personnel. 7 the patient should be referred to hospital for assessment as directed by local health authority regulations, after rescheduling the dental appointment. ideally, the health authority should arrange transport to hospital or a sars clinic and all personnel involved must be informed and wear suitable protective garments. 7, 8 dental management should be limited to the control of pain and infection in consultation with the patient's physician if indicated. no confirmed sars cases with active infection should be treated in a general dental practice. laboratory data indicate that the sars-cov survives at room temperature for up to 2 days provided the conditions are optimum. for instance in cell-culture supernatants only one log reduction in viral load was noted at ambient temperature after 2 days. 9 therefore, if informed by a physician or the local health authority that a patient recently treated at the dental surgery has been confirmed to have sars, the following measures should be adopted: 1, 7, 8, 10 • notify all persons (contacts) who were in the office within a 48-hour period from the time when the sars patient was present. hpa advises that these contacts should stay indoors and keep contact with other people to a minimum for a period of 10 days from the time of last contact with the case. • advise all 'contacts' to inform their general practitioner (gp) immediately. they should keep in touch with the gp daily and seek medical advice as soon as symptoms develop or when recommended by the gp. the contacts should be monitored but need not to be in isolation unless symptoms appear. • the dental office should be thoroughly disinfected using hospital grade germicide, and remain closed for at least 48 hours from the time when the sars patient was present before re-opening 3. dental personnel following unprotected exposure to sars patient hpa has recommended that exclusion from duty is not necessary for healthcare personnel after exposure if they remain asymptomatic or have followed normal infection control procedures 11 (the same rule applies to personnel who have travelled to a highrisk area). they should be monitored daily for fever and respiratory symptoms. exclusion from duty is recommended if symptoms develop during the 10 days following unprotected exposure to sars patients (or visit to high-risk areas), and for 10 days after the resolution of symptoms. 12 these personnel should always wear protective surgical masks irrespective of whether they are treating patients or not, during the 10-day observation period. close contact with sars patients within the past 10 days hpa considered 'close contacts' to be family, friends or healthcare workers who lived with, or who had direct contact with respiratory secretions, body fluids and/or excretions (eg faeces) of possible or probable cases of sars (see below), while that case was symptomatic. 7 examples of close contact include kissing or embracing; sharing utensils, close conversation, physical examination and physical contact. 5 they should be managed by pharmacological means over the 10-day isolation (incubation) period. any acute symptoms that require immediate attention (eg temporisation or emergency endodontics) should be treated only if aerosol and splatter generation can be prevented or minimised by measures outlined below. otherwise the patient should be rescheduled. in high-risk areas where there is a current or recent sars outbreak, a person may have contracted the sars infection leading to sub-clinical infection. further, individuals who have recovered from sars may carry the virus beyond the 10-day isolation period. 13 the infectivity of these patients is unknown. 14 there is a dilemma regarding dental management of these symptomless individuals. on one hand, aerosol generating or potentially cough or vomit inducing dental procedures increases the risk of cross-infection whilst on the other, patients' well-being is compromised if treatment is not delivered. some may consider this as unethical and ostracisation of those who have suffered sars. treatment planning and work practice should therefore be modified as stated above to minimise aerosol generating procedures and, according to some authorities, to take into considerations an approach to cohort convalescent cases for up to 3 weeks from the onset of illness. 15 corticosteroids are used in many centres for the treatment of sars. as even a short-term use may interfere with adrenal cortical responses 16 steroid cover may have to be considered as appropriate. a comprehensive review of dental procedures that incorporate universal and standard precautions is beyond the remit of this article as many recent reviews are available on this subject. 17, 18 rather we outline below special precautions that may be taken in dentistry to minimise droplet and aerosol production including the prevention of the gag, cough or vomiting reflexes leading to aerosols. all the measures outlined below need not be implemented at all times. rather the practitioner should be cognisant of these and implement them appropriately as dictated by the clinical scenario. • proper patient positioning and behaviour management is important. the patient should be relaxed and comfortable. sedation may be considered and hypnosis has been reported to be useful for some patients. 19 • retraction and suction must be performed with care • intra-oral radiographs, especially bite wing and posterior films, may stimulate the gag reflex and one may consider using extra-oral views for screening purposes eg the opg or the oblique lateral views instead of bite wings. 20 • trays may need to be adjusted for impression taking. very sensitive patients may require anaesthesia of the oral mucosa before impression taking. 21 the use of topical spray for subduing the gag reflex is contraindicated to avoid the risk of an aerosol being generated. lozenges may be used instead but its effect is not fully studied. 19 cad-cam technology, may be useful in some cases, to obviate conventional impression taking. 22 • patients suffering from traumatic injuries may have a significant amount of blood in the oral cavity. the reflexes may be induced if blood is swallowed or aspirated so effective evacuation is important. to minimise the likelihood of airborne disease transmission via droplets or aerosols, the dental team adopts the following: 1. reduction or avoidance of droplet/ aerosol generation 2. use of rubber dam isolation 3. use of pre-procedure mouthwash 4. dilution and efficient removal of contaminated ambient air 5. disinfect air/aerosol generated 6. adoption of contact precautions 33 although these results cannot be directly translated to include sars-cov, care should be exercised when these units are used. rubber dam effectively isolates the operating field and its use is well known to prevent or minimise the generation of potentially infectious splatter and aerosol. 34, 35 for the majority of restorative procedures, eg operative and endodontic treatments, the application of rubber dam and the use of high volume evacuation will significantly reduce the risk of droplet transmission and help control the reflexes. • for crown and bridgework, treatment planning may be altered to incorporate rubber dam application. for example, crown margins may be placed supragingivally or a split-dam procedure used. • rubber dam can be applied during tooth preparation for dentures. • adjuncts such as light-cured block out resin (eg opal dam ultradent) can be used where effective isolation by rubber dam cannot be achieved (eg repairing a conventional bridge). a pre-procedural 0.12% chlorhexidine mouth rinse can reduce the microbial load of saliva, and by implication a resultant aerosol due to instrumentation. 36 although the effect of chlorhexidine gluconate on human coronavirus is unknown it is effective against many respiratory viruses, like herpes and hiv. 37 this could be performed through using one or more of the following measures, namely: high volume evacuation (hve), improving the general ventilation and effectively controlling the airflow patterns and filtration of the circulating air. in clinics where air-conditioning is not available all windows should be kept open to encourage natural ventilation as much as possible. high volume evacuation (hve). hve prevents or minimises the dispersion of infectious droplet nuclei into the air by removing them at the source as they are emitted. it is important that the filters in the suction apparatus are cleaned daily in order to maintain its efficacy and the exhaust air vented outside to prevent recirculation. extra-oral evacuation devices and special aerosol reduction devices (ard) designed for use in conjunction with ultrasonic scalers are now available and are considered useful in further reducing the amount of droplets and aerosols. 36, 38 general ventilation. the air quality may be improved by controlling the airflow patterns. the ventilation systems should be designed such that fresh incoming air mixes with and dilutes the contaminated ambient air and the mixture is then removed by an exhaust system. air stagnation or short-circuiting of air directly from the supply to the exhaust is thus prevented. an optimal pattern of airflow (eg air movement from the ceiling towards the floor area) with a minimum of three air changes per hour (ach) is generally recommended for dental surgery settings. [39] [40] [41] air filtration. air filtration could be effectively performed by using high efficiency particulate air (hepa) filters that achieve a particle removal efficiency (pre) of 99.97% at 0.3 µm. although aerosols may have a smaller diameter, testing has shown that smaller particles do not penetrate as readily as 0.3 µm particles. 42 hepa filters may therefore be used in exhaust ducts or any fixed or portable room-air cleaners. 43 its use in dentistry may still be controversial as: • it is difficult to efficiently direct the flow of aerosol towards the filter. • the amount of aerosol filtered is limited per unit time and dental procedures generate a large amount of aerosols in a relatively short period of time thus overloading the device. • filters have to be leak-proof to be effective. • the air inlet and exhaust are adjacently situated in small units (eg those suggested for use in relatively small spaces as in dental clinics) thus causing 'shortcircuits' and reducing the filtration efficacy. 41 a number of new air disinfection systems are commercially available. however, the technologies used are varied and their efficacy in dental clinic settings or indeed against the sars-cov are as yet unproven. these are outlined below: ultraviolet germicidal irradiation (uvgi). ultraviolet radiation is produced by using mercury vapour arc lamps at a wavelength of 253.7 nm, within the uv-c bandwidth of the electromagnetic spectrum. it damages the dna of microbes rendering them non-infectious and is effective against a wide range of airborne pathogens. 41 the efficacy of uvgi depends on: • energy generated ie the intensity of uvgi. 44 • air movement ie amount of aerosol passing the device per unit time. 44 • whether microorganisms are protected by moisture or particulates, and • the duration of the exposure. at present these devices are primarily used as wall-mounted fixtures in some health institutions. they are thought to offer effective filtration against fungi, viruses and bacteria including tubercle bacilli and anthrax spores. 41 their installation, use and maintenance have to be closely monitored to prevent occupational hazards. 45 the use of uvgi in dental surgeries is unproven. photocatalytic oxidation (pco). photocatalytic oxidation (pco) is based on the principle that irradiated titanium dioxide (tio 2 ) produces reactive oxidising radicals that disinfect adsorbed aerosols by oxidising their volatile organic content. 46 this technology has been incorporated in room air decontamination devices although their performance is significantly affected by the water content of the air stream. other factors that may affect its efficiency include temperature, initial contaminant concentration, flow rate and the light intensity. 47 ozone air purification. the high oxidation potential of ozone is used in a number of air purification products although it is not used in dentistry for this purpose. the action of ozone against microorganisms and its use in treating root caries lesions has been described. 48 however, the level of ozone has to be monitored as excessive levels may cause inflammation and impaired lung function and patients with respiratory problems such as asthma may be particularly sensitive. 49, 50 molfino et al. 51 showed that even low ozone concentrations could increase the bronchial responsiveness to allergens in atopic asthmatic subjects. aerosols containing the sars-cov may be deposited on dental surgery surfaces especially in close proximity to the surgical areas. further, the sars-cov has been shown to survive for up to 2 days on fomites (much longer than the influenza virus or hiv) and, contact with sars-cov particles-laden organic or inorganic debris is considered a significant mode of transmission of sars-cov. 13, [52] [53] [54] the established practices of universal/ standard precautions already include protocols that effectively deal with this issue. the following points are highlighted for the prevention of sars-cov infections: • thorough hand washing should be done frequently and after treatment, contact with patient or fomites and before or after handling protective gear. it is a critical measure in controlling the spread of infection 55 a note on personal protection equipment (ppe) • masks have been shown to be useful against nosocomial transmissions of sars. 54 as the most penetrating particulate size is 0.3 µm, a mask with a specification of pfe (particle filtration efficiency) 99% (or above) at 0.1 µm may be more useful although it is uncomfortable to wear for a prolonged period. • hpa recommends the use of usa standard n-95 respirator or the european standard en149:2001 ffp2 for routine airborne isolation precautions. use of higher levels of respiratory protection may be considered for certain aerosolgenerating procedures when treating confirmed or highly suspected sars cases. • masks or respirators must be changed according to the manufacturer's recommendations. furthermore, the filtering efficiency of a mask is only as good as its fit or the moisture content. therefore masks and respirators should be fit checked and always discarded if moist/ wet. • eye protection and face shields are also recommended when there is a potential for splattering or spraying respiratory secretions. 40 • long cover gowns should be worn and sleeves secured under the gloves to prevent exposure of any part of the forearm. re-usable garments should be changed when visibly soiled or penetrated by fluids and placed in marked containers after use. contaminated garment should be laundered using a normal laundry cycle. 57 it is the duty of all dental professionals to maintain a safe practice environment free from infectious hazards. the principles of universal precautions is widely advocated and followed throughout the dental community. however it is believed that in the wake of the sars crisis, practitioners should pay heed to additional precautionary measures now termed standard 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