The South Wales Peer Review Group: A Case Study in Collaboration Part 2

Clinical procedures

There remains considerable ongoing debate regarding the relative risk levels associated with different aspects of orthodontic treatment, and how this could be potentially related to disease spread, particularly in relation to the generation of aerosols and the duration of fallow time. At the time of discussion, the British Orthodontic Society¹ was working on the basis of its Aerosol Generating Procedure (AGP) document and, as such, the conversation in this domain closely followed that protocol. Recently, however, these guidelines have changed,² although uncertainty still exists in this area, which highlights the need for further discussion in future.

The most contentious area which did not achieve consensus revolved around the designation of rinse and spit as a high or low risk event, owing to the risk of splatter.³ It is important that a peer review forum retains its characteristic of being a safe space for the sharing of ideas and, by extension, must be a forum where dissenting views are welcome. Some in the group have, or will eventually, eliminate the use of the spittoon in their clinical setting while the alert level remains heightened. Others will innovate through the use of high-speed suction equipment. This was a good example of how clinician/department discretion will come into play as we navigate the various ambiguities that the differing guidelines present.

Personal protective equipment

One of the most controversial topics during the pandemic has been the provision and availability of appropriate personal protective equipment (PPE) (Figure 3) to frontline workers. Not only has there been a supply problem, due in part to inadequate pandemic planning and disruption to supply chains, but there has also been a problem establishing what level of PPE is required for varying tasks. Somewhat adding to the confusion was the alteration of the classification of COVID-19 on 19/03/2020, where it was no longer considered to be a high consequence infectious disease (HCID) in the UK,⁴ which in turn led to the altered guidance regarding PPE.⁵ Some have argued that this was associated, and perhaps driven by, supply shortages, thereby raising further questions around the reliability and the evidence base of the guidelines.⁶

With reduced disease transmission in the community, and following on from a discussion as to what are high or low risk orthodontic procedures (Figure 4), there remains uncertainty within the specialty with regards to what PPE is appropriate to safeguard both staff and patients. In this section, insights from Ireland are discussed, where alert levels had been reduced and dental activity resumed before the UK. Of particular interest was how primary care practices were able to navigate the challenges of sourcing PPE and the difficulties associated with working extended hours with restrictive masks and face shields. One of the concerns raised was the quality of the equipment available on the open market. Experiences from a primary care practice advised on the need to secure Quality Assurance Certification and shared information for the regulatory bodies who were certifying the quality of masks.⁷ Practice owners and associates tended to communicate these findings via closed social media groups, in which members of SWPRG were often participants or observers. Platforms such as WhatsApp® or Messenger® allowed members of the profession to keep in touch and share good practice.

Triage, risk assessment and patient preparation

It was recognized that, as clinical activity increased, it would be necessary to carry out risk assessments of patients invited to attend the clinic, in the spirit of contributing to the continued reduction of disease transmission. Consensus was gained as to the information which would need to be gleaned from patients, particularly those pertinent to symptoms of COVID-19, and what information would need to be disseminated at the time of the pre-appointment triage call (Figure 5). For example, patients would have to be made aware that attendance to the clinical setting may expose them to increased risk of contracting COVID-19. Patients would also need to be made aware that, if feasible, they may be asked to enter the clinic alone in light of social distancing rules. This would be dependent on the support-needs of the individual patient and this would require consent of the patient and the parent/guardian, particularly for young and/or vulnerable patients. Additional practice safeguarding measures were discussed. Patients should also be pre-warned of the need for staff to wear PPE, so that those who are already anxious of the clinical setting know what to expect in advance, and that the appearance of staff does not unnecessarily raise alarm or tension.

In addition to the pre-appointment triage discussions, an interesting dialogue developed around patient management at the time of the appointment. Consensus was quickly formed on the need to measure and record temperature, to ensure proper hand hygiene, and for waiting areas to be either tightly controlled and managed, or eliminated completely. Evidence was presented on the use of pre-operative mouthrinses which reported that pre-procedural mouthwash, using either sterile water or chlorhexidine, increased the biodiversity and bacterial load of aerosols generated by a slow speed hand-piece during debond.⁸ Conversely, however, there is some evidence that suggests that the virus may be vulnerable to oxidation and therefore the use of a pre-op oxidizing mouthwash, such as with hydrogen peroxide or povidone iodine, may reduce the viral load in saliva.⁹ It's reported that this has been employed extensively in Italy during the current crisis.¹⁰ Ultimately, this will be balanced with the risk of splatter associated with the act of discharging the mouthwash and, as discussed previously, will be down to clinician/department discretion.³

Clinic zoning and layout

Many of the difficulties that will be faced by clinical services, both in primary and secondary care, involves the need to reconfigure the departmental layout to reduce risk of disease transmission and cross infection (Figure 6). Layout may need to accommodate high-risk patients, high-risk staff and/or high-risk procedures. The extent to which this is possible will depend on the footprint and pre-existing layout of each department, and is likely to impact most significantly on open plan poly-clinics, such as those seen in teaching institutes. During this section, the importance of having a recorded measure for the rate of air exchange in each room was discussed. This may have an impact on the fallow time required to allow for sufficient air changes to occur to reduce the amount of aerosol present and also to allow residual aerosol to settle between AGP activity, prior to the decontamination process being commenced. For standard rooms with six air changes per hour, this is considered to be 60 minutes according to guidance based on advice from the New and Emerging Advisory Group (NERVTAG).¹¹ The ability to determine whether this time can be shortened could be significant in increasing the throughput of patients, whilst at the same time recognizing the need to reduce footfall and adhere to social distancing (Figure 7).

Prioritizing

The final section looked at how teams may prioritize patients at the point of resumption of activity. Many patients will have not been seen for over 3–6 months at the time alert levels are relaxed and there are a multitude of ways that patients may be priority assessed for appointments.

Experiences from Ireland, where they had recommenced clinical activity comparatively early, provided insights into how various plans were formulated for resumption of treatment. Patients with complex mechanics, such as asymmetric inter-arch traction, and patients with previous broken appliances, who are either in discomfort or resorted to self-administered adjustments at home, were considered high priority. Furthermore, those who have been waiting an extended time were also afforded similar higher priority (Figure 8). There were anticipated complexities in the UK as resumption of activity in the first level of de-escalation would only allow for urgent treatment or those classified as Non-AGP to be carried out. Given the presence of fixed appliances in situ (an active medical device), and owing to the potential risks associated with this, it could be argued that all orthodontic patients in active treatment who have not been seen for many months constitute a significant degree of urgency.

This crisis is likely to permit fast-tracking of many technological advances and innovations, the most significant of which may be the wholesale adoption of virtual clinics. NHS Wales, through its various Local Health Boards, has rolled out the Attend Anywhere® platform,^12,13 designed to permit clinician interaction with patients and parents without the need to attend clinic physically. Experiences of this platform, including the management of functional appliances, retainer reviews, interceptive treatment progress and space closure monitoring, were shared. There may be scope in the future to introduce the virtual platform to the multidisciplinary clinic setting and perhaps consider its use in referral triaging to help reduce waiting times and aid prioritization.

Future sessions and reflections

Inevitably, it was not possible to discuss all the challenges and all the issues that this pandemic has created for dentistry in general, and orthodontics specifically, in one session.

As part of the reflective process, participants were invited to offer their thoughts as to what future sessions may involve. It was not surprising that those involved in teaching and academia would in the future like to discuss the impact this crisis will have on specialty training. Reduced clinical activity, changes to open-plan clinic layouts, delayed professional examinations, and reduced time to complete cases for exam presentations, are some of the issues that have already arisen from this crisis, as well as the potential financial implications to university funding if there are fewer overseas postgraduates in the future. Similarly, the direct supervision of therapists, both qualified and those in training, has similar challenges, as a result of multiple episodes of donning and doffing of PPE to prescribe and review patient treatment. Solutions to these issues will need to be discussed.

Those involved in recruiting and retaining staff expressed interest in exploring topics looking at such areas as: furloughing schemes, remuneration and commissioning, as the uncertainty over the future of NHS dentistry begins to increase.

However, opportunities do arise from crises and the fast-tracking of digital technologies in the form of 3D intra-oral scanning and, with virtual consultations likely to become standard across orthodontics, these are just some of the possibilities that could result in the future-proofing of the profession. In addition to this, cross-infection protocols are also likely to become even more robust, elevating dentistry as a model for disease prevention across the healthcare sector as a whole.

In terms of the peer review session as a model for discussing quality improvement and management strategies, participants reflected on whether the specialty should be lobbying key policy makers to mirror this kind of collaboration when shaping the landscape for dentistry beyond the pandemic. It is not inconceivable for the Chief Dental Officers of the devolved nations to collaborate in such a way, co-ordinating closely with unions, such as the British Orthodontic Society (BOS) and British Dental Association (BDA), and other stakeholders, to brainstorm on how best to provide an oral health service fit for purpose for the decade to come. In the age of digital communication, sessions could be recorded and shared with key stakeholders in the spirit of transparency and with a framework of inviting contributions and ideas from those who will be delivering and receiving the service in future (Figure 9).