Written Evidence Submitted by
The Association of Clinical Oral Microbiologists (ACOM)
(CLL0080)
The Association of Clinical Oral Microbiologists (ACOM) wish to provide evidence on the issues linked to;
Government communications and public health messaging and
the UK’s prior preparedness for a pandemic
Background: The Association of Clinical Oral Microbiologists comprises UK specialists formally trained (FRCPath) as Clinical Microbiologists with a background of a dental degree. The purpose of the GDC specialty of Oral Microbiology is the prevention and optimal management of infection throughout all areas of dentistry. The specialty provides support for dental health care professionals in the following domains; diagnostic clinical microbiology; the management of orofacial and maxillofacial infection; infection prevention and control; decontamination of medical devices; and antimicrobial stewardship. In addition, members are embedded within NHS diagnostic microbiology units, infection prevention and control (IPC) and health protection agencies.
Workforce issues linked to pandemic preparedness
In relation to the current pandemic ACOM welcome the opportunity to highlight concerns over the ability and capacity of the dental profession to respond appropriately.
An adequately resourced UK wide Clinical Oral Microbiology (COM) specialist network would have been available to advise the Government and impact positively in the following areas: -
1. Risk assessment of aerosol, droplet and splatter during dental procedures.
Dental surgery is a unique healthcare profession in that the vast majority of patient interactions involve exposure to aerosolised particles, droplet and splatter from upper respiratory tract secretions. Prior to the pandemic standard infection control precautions in dentistry were well established and adhered too. However, these underlying principles and evidence were not widely appreciated or well communicated leading to a lack of confidence amongst non-specialists for extrapolation and proportionate risk assessment in the context of a new respiratory virus with possible opportunistic airborne transmission. Due to the lack of oral microbiology specialists, many dental professionals were either unsupported or supported by medical IPC teams. Whilst this input is greatly appreciated, the lack of expert knowledge and capacity prevented clear, proportionate advice and communication. This lack of specialist knowledge of the existing evidence directly affected messaging on related factors including use of PPE, dental surgery ventilation and fallow time.
2. Dental surgery ventilation and fallow time
The focus on building ventilation to mitigate airborne transmission risks during the pandemic highlighted that many dental practices and dental hospitals were failing to meet the required building regulation standards for clinical treatment areas within healthcare premises which have been in place since 2006 (2). We also highlight that the proposed additions to HTM03-01 (3) for dentistry are not specific or practical enough and HTM01-05 urgently needs updating (published 2013) as this is the only document most dentists are aware of (4). Furthermore, recommended continuing professional training has been focused on decontamination of instruments rather the infection prevention and control in its entirety.
The remobilisation plans from the 4 Nations (5) quoted two different sources of risk assessment to generate fallow times following dental aerosol procedures that had different recommendations (6,7). Such inconsistencies and in some cases lack of scientific transparency on recommendations (7) seed confusion and lack of confidence in guidance.
3. Consistent messaging on the use of PPE
Specialist knowledge of the IPC principles underpinning operative dentistry, the behaviour of dental bioaerosols and working practices in a range of clinical situations including supervisory roles, would have led to more timely and consistent messaging on the use of PPE.
4. Communication and public health messaging for the management of acute oral infections to the dental HCWs and the public. Recommendations included the use of antibiotics to treat dental pain (8) which contradicted existing health agency advice (9) (“antibiotics don’t cure toothache”) leading to inappropriate and excessive antibiotic prescriptions (10). Furthermore, this recommendation undermined the long-standing initiatives to educate dental professionals and the public about the need for clinical dental treatment interventions (9). Whilst it is understandable that we were dealing with a unique pandemic situation, some of delays in setting up the urgent dental care centres may have been avoided with the availability of appropriate specialist advice as listed in points 1-3.
During the pandemic, the availability of COM specialists has been further reduced with additional demands on their time. Due to their background and medical microbiology training, some have been redeployed in roles such as covering for Medical Microbiology colleagues, support for National Reference Facilities and CoVID19 vaccine trial site co-ordination. In addition, specialists are employed in academic posts and have been involved in the continued delivery of teaching and assessment of undergraduates and post-graduates in the prevention and management of infection and antimicrobial stewardship. The few remaining members contributed when able to relevant working groups and rapid reviews e.g. dental aerosol mitigation and ventilation.
In conclusion, we wish to highlight the significant short fall in workforce planning to provide specialist infection prevention and control support to the dental profession. Every UK dental hospital and every member of the dental team should have access to a suitably trained, qualified, and experienced clinical microbiologist. ACOM has lobbied various Government, Royal College and higher education agencies for the last decade warning of these shortfalls. ACOM members have contributed to the development of comprehensive specialty commissioning guides and prepared business cases at the request of the CDOs for the delivery of specialist services in England and Wales. Further support to practitioners and hospitals could be provided by training additional clinical staff and deploying through a Regional hub and spoke model centred around dental hospitals, linked with local Clinical Microbiology and IP&C teams, dental public health and health education institutes.
Recommendations linked to Government communications and public health messaging and the UK’s prior preparedness for a pandemic
1. Support for the provision of a UK wide Clinical Microbiology service to provide equity of access to all dental health care workers (as detailed in Service Delivery proposals for England and Wales).
2. Revision of Government communications, such as HTM 03-01 and HTM 01-05 to ensure they reflect current state of the art, relevance to clinical dental practice and in an accessible format for dental healthcare workers.
3. Development of UK Wide Dental Specific Training in Infection Prevention and Control and future pandemic preparedness.
Submitted by
Deborah Lockhart
Caroline Pankhurst
Riina Richardson
Noha Seoudi
Andrew Smith
Melanie Wilson (Chair ACOM)
References
1. General Dental Council. https://www.gdc-uk.org/
2. Scottish Health Planning Note (SHPN 36 part 2) NHS Dental Premises. Health Facilities Scotland, July 2006. Brief description: Building regulations setting out required air changes
in dental surgeries (10 air change per hour) as minimal objective for Health and Safety at Work Requirements.
3. Heating and ventilation systems Health Technical Memorandum 03-01: Specialised ventilation for healthcare premises. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/144029/HTM_03-01_Part_A.pdf
4. Decontamination in primary care dental practices (HTM 01-05). https://www.gov.uk/government/publications/decontamination-in-primary-care-dental-practices
5. Four Nations National Guidance (October 2020). COVID-19: Infection prevention and control dental appendix.
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/928034/COVID-19_Infection_prevention_and_control_guidance_Dental_appendix.pdf
6. SBAR Ventilation, water and environmental cleaning in dental surgeries relating to COVID-19 (July 2020). Brief description: A Short Life Working Group (SLWG) was established to review and make recommendations for remobilisation, development of guidance and other related activities (e.g. training) with respect to ventilation (and associated aspects) within dental practices in relation to Covid‐19. The contribution that factors play in mitigating the associated risk from Aerosol Generating Procedures (AGPs) were explored.
https://www.scottishdental.org/wp-content/uploads/2020/08/Ventillation-Final-Copy-1.pdf
7. Rapid Review of Aerosol Generating Procedures in Dentistry. https://www.sdcep.org.uk/published-guidance/covid-19-practice-recovery/rapid-review-of-agps/
8. UK sources of advice for managing acute dental infections during the pandemic
England:https://www.fgdp.org.uk/sites/fgdp.org.uk/files/editors/2020.03.25%20CDO%20England%20COVID-19%20advice%20letter.pdf
Wales:
https://www.fgdp.org.uk/sites/fgdp.org.uk/files/editors/2020.03.23%20CDO%20Wales%20COVID-19%20advice%20letter.pdf
Scotland: https://www.fgdp.org.uk/sites/fgdp.org.uk/files/editors/2020.03.23%20CDO%20Scotland%20COVID-19%20advice%20letter.pdf
Northern Ireland
https://www.fgdp.org.uk/sites/fgdp.org.uk/files/editors/2020.03.23%20CDO%20NI%20COVID-19%20advice%20letter.pdf
In brief, Government advice: “Due to the COVID-19 pandemic, dental practices in the UK were instructed to stop all routine dental care during lock down. Dentists were instructed that dental emergencies should be managed with advice, analgesia and antibiotics (AAA) and there should be no face to face contact with patients.
Urgent dental centres (UDCs) have been set up to see patients where AAA isn’t sufficient to manage extreme pain or swelling. The UDCs will not see patients face to face until they have had at least one course of antibiotics or more. Antibiotics are often an unsuitable treatment for most dental emergencies, such as reversible pulpits or mobile / broken teeth.”
What the guidelines say: ‘The majority of uncomplicated infections of dental origin can be successfully treated by the removal of the origin of source of the infection by drainage of the associated abscess, removal of the pulp contents or extraction of the associated tooth. Antimicrobials are only indicated as an adjunct to definitive treatment where there is an elevated temperature, evidence of systemic spread and local lymph gland involvement.’ Faculty of General Dental Practitioners
9. Dental antimicrobial stewardship: toolkit. https://www.gov.uk/guidance/dental-antimicrobial-stewardship-toolkit
10. Shah, S., Wordley, V. & Thompson, W. How did COVID-19 impact on dental antibiotic prescribing across England?. Br Dent J 229, 601–604 (2020). https://doi.org/10.1038/s41415-020-2336-6. Brief description: Antibiotic prescribing in April to July 2020 was 25% higher than April to July 2019, with a peak in June 2020 in England. 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.