Our former Chair and member of SDCEP’s working group, Mick Armstrong, provides insight into the new report on AGPs and fallow time and outlines what needs to happen to turn these recommendations into guidance.
Aerosol-generating procedures (AGPs) have become the single biggest point of contention in dentistry since the outbreak of the coronavirus pandemic. Initially relegated to the confines of urgent dental care, under strict protocols of enhanced PPE, the return to practice has meant AGPs are further restricted by fallow time rules. This hour-long period in which treatment rooms must remain empty has had severe repercussions for practice throughput and further punished a sector already on its knees. The profession has cried out for evidence, detail and guidance and this review hopes to provide some answers.
Rapid Review of Aerosol Generating Procedures in Dentistry - SDCEP
I truly believe that this is the report the profession has been looking for. It reflects the fact that the science is not comprehensive and outlines how we can best ensure public and staff safety. We now need and eagerly await Government policy and hope any new instructions reflect the tireless work by the Scottish Dental Clinical Effectiveness Programme (SDCEP.
“It almost felt like being a student again waking up to spend two hours on aerosol physics or epidemiology on a Thursday morning.”
Towards the end of June the Office of the Chief Dental Officers asked the Scottish Dental Clinic Effectiveness Programme to get to grips with the issues frustrating the profession.
Held in high regard for their outstanding work on antimicrobial resistance, antibiotic prophylaxis, dental amalgam and periodontal care, and praised by all four CDOs, SDCEP immediately convened a multidisciplinary working group. It was tasked with identifying and appraising all available evidence in relation to the generation and mitigation of AGPs in dentistry and the associated risk of COVID-19 transmission. The aim was to reach a number of agreed positions to inform policy and clinical guidance.
I joined SDCEP as a BDA representative and as part of an ’all key stakeholder’ group. I can honestly say I have been hugely impressed with their dedication, commitment and expertise - SDCEP mean business. For almost three months I have worked alongside these remarkable academics, virologists, physicists, public health officials, and other wet fingered dentists. The process engulfed our lives as hours of virtual meetings piled on top of intensive review work. It almost felt like being a student again waking up to spend two hours on aerosol physics or epidemiology on a Thursday morning. But that was what was necessary to compile this report.
The lack of evidence
"Aside from SARS and MERS, there is little historic research related to aerosols and disease transmission."
SDCEP started by assessing past and current scientific evidence for aerosols and mitigation factors from around the world. One thing became clear immediately – the existing evidence is, for our standards, of low quality. Aside from SARS and MERS, there is little historic research related to aerosols and disease transmission.
Consequently, we could not draw recommendations from the evidence alone but that is not the point of this report. This is not government guidance. It is a review that aims to inform policy makers.
We have compiled and presented our ‘considered judgements’ to help the profession at this unprecedented time. Each judgement has had to be supported by a majority of 75 per cent of the review board to strike the best path forward.
It is a living document and our group will be recalled when new evidence arises or developments unfold. Should the pandemic become more or less severe then our recommendations might become stricter or more relaxed.
What does the report say?
SDCEP report outlines our methodology and agreed positions and is a series of recommendations on the generation and mitigation of aerosols in dental practice and the associated risk of COVID-19 transmission.
As professionals, we are all familiar with AGPs but for the first time we now delineate between different categories. There are high-risk procedures that require fallow time and lower risk procedures that can be dealt with using standard control precautions.
"Mechanical ventilation ensuring at least ten changes per hour should bring fallow time down to ten minutes."
The working group has agreed that a pragmatic fallow time of between 10 and 60 minutes is recommended to reduce the risk of coronavirus transmission through the use of a series of mitigation techniques.
The use of high-volume suction, already estimated to be used by 94 per cent of practices, could reduce fallow time to 20 minutes if applied effectively. Likewise, the use of rubber dams for restorative dental procedures that produce aerosol is also recommended.
But the key to reducing fallow time is ensuring a high ventilation rate. It is essential that dental care providers investigate the air change rate to ensure they comply with guidance that treatment rooms should have at least ten air changes per hour - an open window is probably not enough. Mechanical ventilation ensuring at least ten changes per hour should bring fallow time down to ten minutes, plus ten minutes cleaning time, in line with our recommendations.
Can this report help practices get back on their feet?
"This is a public health measure and it is a reasonable ask of the government to help get dentistry back on its feet."
If fallow time can be reduced to 10 minutes then dentist capacity could increase significantly - possibly up to between 60 and 70 per cent of pre-COVID 19 capacity. That would vastly improve the current threat to dentist viability and really begin to tackle the worrying impact that lockdown has inevitably had on the population's oral health.
There are, however, potentially vast costs involved in getting to that stage - as high as £35,000 for some large practices (£3-4K per surgery). It is clear that capital investment in dentistry is essential to move forward but this is not as frivolous as a single practice taking on some renovation. This is a public health measure and it is a reasonable ask of the government to help get dentistry back on its feet. This act would show the kind of commitment to our profession that we have needed since the outbreak first took shape.
Where do we go from here?
Our CDOs in conjunction with public health officials and the NHSE&I infection control team should produce the formal guidance on the back of this report.
Don’t hang your hat on SDCEP’s report just yet - wait for the official mandate before spending any money or making significant changes at your practice. We also await news on funding across the four regions as new public health measures aimed at limiting the spread of the virus kick in.
We expect this all to become clear very shortly.