Public attitudes on returning to dentistry post COVID-19

hygienistsWith some patients hesitant on a return to dental practices, Michael Heffernan discusses ways hygienists can keep attracting patients.

We are at last returning to see our patients. But not surprisingly there is a large amount of trepidation on all sides; dental teams and patients.

A national survey of 541 adults in the UK by Dr Heff’s Remarkable Mints found worrying results for patients’ dental health and the future of dental practices:

  • 80% of adults think that dentists and hygienists will have to work hard to reassure patients that their practice is safe and hygienic
  • one-in-three UK adults will visit their dentist less frequently after ‘lockdown’
  • Half of UK adults will cancel or delay planned treatments if dental fees increase due to the cost of personal protective equipment (PPE).

A changing landscape

In my 30 years of dental practice we have not seen a landscape like this. Hence, we thought it appropriate to consider the unique factors that hygienists face to keep patients safe as well as their profession alive.

There are already very good levels of infection prevention and control in dentistry. However, COVID-19 is still unknown in many ways and so we require additional precautions. The main transmission is considered to be via droplet infection. However, Peng et al (2020) considers smaller particle size aerosols a risk too. Therefore dentistry is now delineating procedures according to levels of exposure risk. This will drive both the PPE requirements and the time for adequate disinfection.

Changes to hygienist appointments

In the UK there are differences with how hygienists work in comparison to dentists. Hygienists often work alone in a room without an assistant. The surgery may be smaller than conventional dental surgeries without access to windows or in a partitioned room with other clinicians. There is a lack of scientific evidence regarding the effectiveness of air filtration systems on removal of COVID-19, although potential investment in HEPA air purifiers might be beneficial (Zhao, Liu and Chen, 2020).

The appointment times are usually 30-45 minutes with high daily patient turnover. Hygienist interventions routinely use aerosol-generating procedures (AGP) to disturb the biofilm of active periodontal/peri-implant disease (Drisko et al, 2000). This aerosol may remain airbourne for 30-60 minutes unless a suitable air exchange is in place within the surgery and current recommendations suggest implementing a fallow period before disinfection routines.

Therefore, there will certainly be challenges to overcome to provide a reasonable treatment experience for patients and to generate income for the hygienist. Options we need to decide on include:

  • Whether it will be possible for a hygienist to use multiple surgeries to avoid long periods of downtime between AGP patients
  • Will provision of a dental assistant be possible to allow help for the hygienist to don PPE safely, and utilise high volume aspiration as it is impossible to implement protective aids such as rubber dams for sub-gingival cleaning procedures
  • How will we pass the additional cost of appropriate PPE onto the patient without putting them off from coming in to the practice?

It appears inevitable that there will need to be changes in how we ‘do’ dentistry and maybe some of these will be for the better.

The silver lining

So where is the silver lining? Well there is some good news from the survey:

  • Three in four adults want to learn how to improve their own dental health to prevent dental disease.

This is fantastic as we know patient home care is the key to all dental disease prevention. Over the past years minimal invasive (MI) dentistry has been on our radar pushing patient motivation, dietary advice and self oral hygiene measures. These are all feasible via virtual consultations. Even the chief dental officer (England) extolled the virtues of MI-online, despite dentistry being gripped in a crisis of just trying to stay afloat (Hurley, 2020)! But are patients ready for this? In our survey we asked about virtual consultation and a dental health app.

  • 5% would have some dental consultation via video, whereas 41% were against
  • 54% were interested in an app that helped regular dental health routines throughout the week whereas 26% were against.

Hence, half the population surveyed would not want to have video dentistry for check ups and unfortunately we do not have demographic data to show if there is a split in age.

On the plus side there does appear to be a place for on-going nudges via an app to improve patients home care. Maybe this is where the hygienist profession can help patients all the more.

The front line of dentistry

We have probably all had time during lockdown to change our behaviour and one of the better angles of CPD is how to positively influence our patients self-care. The ‘Behaviour Change Wheel’ (Newton and Asimakopoulou, 2017) is a motivational strategy. This along with goal-setting and review of progress can be undertaken as a virtual hygienist visit. Maybe payments through insurance/capitation schemes will allow hygienists to have an income provision for this ‘virtual’ therapy.

However, in many instances it is impossible to solely treat patients remotely. There are a number of patients that need hygienist treatments such as those with dexterity issues or active infection. Historically hygienists worked with mainly hand instrument scaling and root planing. These are non-AGP so can still be carried out (Drisko et al, 2000). Disruption of the periodontal biofilm is a mainstay in periodontal therapy. It has been adopted as part of the EMS ‘guided biofilm therapy’ routine. However, bacterial colonisation will recur immediately with reservoirs elsewhere in the mouth. Therefore just removing the biofilm is not enough if the patients oral hygiene is also not maintained. There is also good scientific evidence to provide additional support for patients at home to avoid harmful dental biofilm recurrence.

In conclusion, we sit at a challenging time in the dental profession. It is impossible to know what the near future will be like for hygienists. We know they are crucial for patients’ dental health. We must find a way to properly protect and support hygienists. They are in the front line of the dental health profession!

In our following article we will discuss more insights from our recent survey and implications for dental practice.

References

Drisko CL, Cochran DL, Blieden T, Bouwsma OJ, Cohen RE, Damoulis P, Fine JB, Greenstein G, Hinrichs J, Somerman MJ, Iacono V and Genco RJ (2000) Position paper: sonic and ultrasonic scalers in periodontics. Research, Science and Therapy Committee of the American Academy of Periodontology. J Periodontol 71(11): 1792

Hurley S (2020) Why re-invent the wheel if you’ve run out of road? Br Dent J 228: 755–6

Newton JT and Asimakopoulou K (2017) Minimally invasive dentistry: Enhancing oral health related behaviour through behaviour change techniques. Br Dent J 223(3): 147

Peng X, Xu X, Li Y, Cheng L, Zhou X and Ren B (2020) Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci 12: 9

Zhao BB, Liu Y and Chen C (2020) Air purifiers: A supplementary measure to remove airborne SARS-CoV-2. Build Environ 177: 106918

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