Dental Surgeon Dr Gurps Singh gives an insight into the conflict Sikh dentists face in continuing to wear turbans and beards while also complying with new PPE guidance.
I never thought my beard and turban would interfere with my profession as a dental surgeon. The concept of selfless service and equality in humankind is central to my faith and has only ever enhanced my profession. Yet when the pandemic hit and routine care ceased I, like many Sikhs, was faced with a situation I could never have anticipated. My faith was in conflict with my profession.
You cannot pass a fit-test if you have a beard
Unlike other dentists working in the urgent dental centre in which I volunteered, I wasn't able to perform any aerosol-generating procedures (AGPs). Since the outbreak of COVID-19, AGPs require level three personal protective equipment, that's FFP2 and 3 masks. These must be face fit-tested and I failed the qualitative fit test (even though I passed the exercises).
The guidance states that there must be no interference between the border of the mask and your face. In effect, having a beard is an automatic fail. Some dentists might choose to shave off their beards, but that was not an option for me. My beard is central to my faith and my right to keep it is protected by the Equality act of 2010 and Human Rights Act 1998. COVID-19 and the new guidance inadvertently discriminated against Sikhs who wear turbans and beards.
Are PAPR hoods the solution?
"PAPR hoods might be a short-term solution… but the problems for dental professionals far outweigh the benefits"
Powered Air Purifying Respirator (PAPR) hoods emerged as a possible solution and I didn't hesitate when the British Sikh Dental Association managed to source one after I raised concerns. A PAPR is a respirator in the form of a hood or helmet that filters ambient air and delivers clean air to the user's face or mouth. It doesn't require any fit testing and has a protection factor 20 which is equivalent to an FFP3 mask.
Over the course of nine weeks I tested five different PAPR brands from various manufacturers and have come to the one conclusion: PAPR hoods might be a short-term solution born within a crisis, but the problems for dental professionals far outweigh the benefits.
1.The power pack is heavy and awkwardly placed
A PAPR hood weighs about 1.5-2.5kg. This weight is entirely on your neck and shoulders or back. This results in neck/back pain and postural discomfort after long treatments. Furthermore, some of the loose-fitting hoods have an internal head fixing that interferes with the turban. This caused me great embarrassment when I discovered, while doffing, that the hood actually lifted up my turban. The other half of the power pack is belt-mounted which prevents you from being able to sit on any chair with a back rest. You have to either stand throughout or rest precariously on the edge of the seat. It is entirely unfeasible that PAPR hoods can be worn for long periods throughout the day.
2. PAPR hoods impede communication
Communication is the cornerstone of good dentistry. It is essential for obtaining patient trust and consent. However, a PAPR hood creates a howling noise around your ears which means you end up having to raise your voice when trying to communicate. It makes for an uneasy atmosphere in the surgery and is terrifying for children in emergency visits. Patients are used to seeing masks, which are now mandatory in shops and commonplace in public life. However, a hood is still very uncommon and its appearance creates anxiety. One patient described it as like being in a science fiction film.
3. They are too expensive
"Currently, finding a sustainable supply chain of replacement hoods and filters is very difficult"
PAPR hoods cost approx. £450 to £1200 which is exorbitant. But it does not end there. One size does not fit all so you need to buy a few and test them. Obviously, in the current climate there is no such thing as sampling and returning. The filter requires a maintenance change and can range from 21 days to 6 months depending on local risk assessments. Currently, finding a sustainable supply chain of replacement hoods and filters is very difficult. And when you can't guarantee supply, you can't become complacent with one brand.
The cycle of buying and testing is ongoing while expenses continue to mount. The idea that we must continue to spend thousands trying to find something that fits and in plentiful supply is implausible. How are we supposed to absorb those costs?
4. PAPR hoods impede dental magnification
PAPR hoods may inhibit your ability to use dental magnification such as loupes with an external light. Using a powered light source is complicated as it needs to be inside of the hood, however this creates a reflective glare from the plastic hood shield. It is also very difficult to make loupe adjustments from underneath the hood. Using a dental operating microscope is also out of the question. This severely impairs the ability to perform micro-surgery competently. I have raised this issue with manufacturers and enquired about cutting a hole into the perspex and plastic shield. Unfortunately, if you alter the device, you remove the certification of protection.
5. PAPR hoods do not have a gender neutral fit
In general, PPE masks have been designed for a male face shape and size. So, it is not unusual for female dentists to struggle with the fit. Many female dentists are therefore also looking for an alternative have also hoped the answer lay in PAPR hoods. Yet out of five hoods tested on the female members of my team, only two fit them. Their head shape and size mean the hoods are also inefficient unless they have adjustable components (waist straps can be adjusted but some hoods do not adjust to the waist). It becomes an incredibly expensive and frustrating guesswork when trying to cater for everyone in the practice.
"There is still a diversity inequality when it comes to PPE"
My conclusion after substantial testing is that there is still a diversity inequality when it comes to PPE. I am currently working alongside a Health and Safety supplier to vigorously test various PAPRs that are suitable for turban wearing Sikh dentists. So far, we are yet to find the perfect match.
Dr. Gurps Singh
BDS (Hons) MFDS RCS (Ed) MSc (Endo)