Definition: The ability to mentally or emotionally cope with a crisis, or to return to pre-crisis status quickly
Origin: 1620-30; from resilire (Latin): to spring back, rebound
By Kelly Gillan, BAOS Council Member
As we all know, healthcare provision is a complex system which is regularly beset by challenging scenarios- perhaps never more so than during the COVID-19 pandemic. As healthcare workers, we are expected to have the capacity to absorb negative conditions, effectively manage them and move forward. Psychological resilience is now widely recognised as a key factor in enabling this, and in maintaining a healthy, robust workforce.
Unsurprisingly, individuals with high levels of resilience have been shown to deal better with stressful events. Individually, we do develop strategies that we turn to in times of change or crisis. In addition however, it has been shown that psychological resilience can be augmented through training – available more routinely through Local Deaneries and Trusts. An interesting starting point to this is to measure your own resilience with the “Brief Resilience Scale”. Are you as resilient as you think?
Whilst working within the UDCC in Newcastle Dental Hospital, my colleagues experienced significant daily challenges with outward signs of resilience. A recent anonymised staff survey however highlighted underlying concerns which were previously unvoiced. It is vital to remember the importance of effective conversation in order to gauge anxiety levels within our workforce. In combination with an insight into personal resilience, we may perhaps more effectively deal with future challenges.
References and resources:
N.Adam, CJ Mannion : The ‘R’ word – do dental core trainees possess it; Br J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.bjoms.2020.04.022
Brief Resilience Scale available at: www.psytoolkit.org
Applications are now open for the 2021 FDS-BAOS Research Grants.
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Trainees, Examinations and Research
Delivery of care, training and education has been very challenging, and continues to be so, during the ongoing COVID-19 pandemic. The impact on trainees has been significant with reduced clinical experience for many. A strategic priority must be the maintenance of training experience. This needs to include the creative development of virtual teaching and surgical experience.
New guidance has been published about supporting clinical academic trainees in the event of a second wave of Covid 19 (CATF Working group COVID-19 Second Wave Principles Final document). The key message from the document is that any future redeployment of Academic Clinical Fellows (ACFs) and Clinical Lecturers (CLs) will be on a voluntary basis. Many ACFs and CLs were redeployed earlier in 2020 with a commitment from NIHR to fund training extensions for those that were. Hopefully the new guidance will minimise any further disruption to clinical academic training.
A number of BAOS Members applied for the Tri-Collegiate Membership in Oral Surgery examination in November 2020, had their applications initially accepted and received confirmation of places, only to then have places retracted. COVID-19 has clearly interrupted normal examination provision and has meant there are a number of individuals who had originally intended to sit the exam in June 2020 and had been rescheduled for November 2020. Whilst this prioritisation was understandable Council wrote to the Examination Board asking that they accommodate all those individuals who had their applications accepted and confirmed. Whilst we received an apology for disappointment caused, the finite capacity and resources meant that no additional candidates could be accepted for November. The Colleges recruited additional examiners in 2019, however, all new examiners are required to undergo training and examination observation before appointment to the faculty of examiners.
There have also been implications for preclinical and clinical research. Many research laboratories have been closed and only recently re-opened with distancing and longer hours to permit safety. Many research projects have inevitably been delayed.
The consequences for patients have been profound. The cessation of routine care has inevitably reduced the referrals for specialist oral surgery care, especially for elective surgery. There is still reduced operating theatre capacity. Waiting times are growing. There are consequences for the wellbeing of adult and child patients who are living with ongoing pain and infection. The household isolation requirements of the pandemic and the financial fallout has resulted in an increase in domestic violence and abuse and facial and dental injury.
Access to PPE is now not such an issue as earlier in the pandemic. Our survey of BAOS members clearly showed that the initial shortage of PPE impacted on the delivery of care. BAOS has continued to contribute to the national response to the COVID-19 pandemic with written submissions and discussion with NHS England and PHE.
Together with other stakeholders we joined the BDA in writing to the Secretary of State, Rt Hon Matt Hancock MP, expressing our concerns about the ‘Waiting time for dental treatment under general anaesthetic’. Some patients waiting for over a year. Many require multiple courses of antibiotics. We have asked that he step in and provide resolution of the problem as a matter of urgency.
The BAOS, along with many other dental organisations, has supported the British Association of Dental Nurses (BADN) in their call for recognition of the contribution of dental nurses to the dental profession. There was been concern for some time about number of nurses leaving the profession every year but the COVID-19 pandemic has highlighted some particular issues for nurses around their poor financial security.
Aerosol Generation Procedures
Gavin, BAOS Trainee Representative, and I have contributed to a Rapid Review Working Group of the Scottish Dental Clinical Effectiveness Programme, ‘Aerosol Generating Procedures in Dental Practice’. This was published on 25 September 2020.
BAOS Annual Conference and BAOS Digital
The 2020 BAOS Annual Scientific Conference at the Assembly Rooms Edinburgh initially scheduled for October 2020 was postponed until 4-5 March 2021. We have now made the decision to postpone our new style two-day conference until 2-4 March 2022 in Edinburgh. Please make a note in your diary
BAOS are soon to launch BAOS Digital #BAOSbytesize. This offering will feature both ‘Conference’ and ‘Regional’ regular events, some exclusive to ‘Members only’ and others free to the world! This is an exciting opportunity for us to deliver high quality presentations and discussion interviews with current thinking on a whole range of interesting and relevant subjects. We will also be providing some of these CPD events jointly with other organisations. Our launch event is with the Royal College of Surgeons of Edinburgh on Thursday 17th November at 7.00pm, ‘Oral Surgery Careers’!
BAOS is soon to open an online BAOS Shop with cool merchandise accessible via our website.
‘Getting it Right First Time (GIRFT) and Coding
Following hospital visits last year the ‘Getting it Right First Time’ (GIRFT) report was due for publication just as the COVID-19 pandemic reached the UK. The NHSEI wisely wanted to incorporate specialty responses into the report and BAOS was pleased to propose innovative ways of working learned from the COVID-19 pandemic.
We have proposed oral surgery education for general dental practitioners, more conscious sedation, greater integration with general healthcare, oral surgeons at the forefront of oral cancer identification, serving vulnerable patients and offering leadership. Delivery of this and more will require more trainees, Specialists and Consultants. More detail can be found as a supplement to this Newsletter.
There has been further recent GIRFT discussion and this has been about NHS Oral Surgery coding. As we know the dental specialty of Oral Surgery (OS) and the medical specialty of Oral and Maxillofacial surgery (OMFS) have considerable overlap in their curricula. The Main Speciality Code has been a problem with with many Consultant Oral & Maxillofacial Surgeons being wrongly coded to the speciality of Oral Surgery.
The Information Standard Notice (ISN) DCB0028: Treatment Function and Main Specialty Standard describes how, from 1 April 2021, a new code for Oral and Maxillofacial Surgery Service (145) has been introduced, and descriptions against existing codes 140 and 144 state that the new code should be used in preference to these codes. We believe that at this time this is an unhelpful change for commissioning, for waiting list management and for service improvement and planning. We understand that it is too late to stop the new code; however, we have supported GIRFT in asking the ‘Treatment Function Maintenance Group’ to change the descriptions against the three codes (140, 144 and 145) to indicate that:
- Codes 140 should be used for clinics that contain oral surgery patients only
- Code 144 should not be used
- Code 145 should be used for clinics that contain a mix of patients that is oral surgery, trauma, orthognathic surgery, oral cancer, skin cancer and diseases of the head and neck out with GDC Oral surgery curriculum
BAOS have been invited to provide by the end of October 2020 any current information regarding our specialties current workforce needs (including any evidence as to specialist to population ratio and future retirements that will affect workforce numbers), our patient population oral health needs (including any treatment complexity breakdown) and any other evidence that we feel is pertinent. This is important and we are working on this.
Professor Paul Coulthard, BAOS President
- BAOS Proposals to GIRFT for innovative ways of workinglearned from the COVID-19 pandemic.
- There is a need to reduce patient volumes in secondary care and enable primary care services to develop. This redirection of patient flow requires the following to be facilitated.
- General Dental Practitioners in primary care should be supported in undertaking routine oral surgery care such as dental extractions as expected of the general dental services contract. This is likely to require educational support largely online and clear advise about and supply of appropriate personal protective equipment (PPE).
- The more complex oral surgery should be referred to Oral Surgery Specialists and Consultants working in both the primary care and secondary care setting. Dentists with enhanced skills who may or may not be on the GDC Specialist List are currently undertaking some of this oral surgery work (‘Level 2’) but as training post numbers increase this work should be undertaken by Specialists. (Currently only 60 NTNs) This work volume will be reduced if General Dental Practitioners are incentivised to undertake ‘Level 1’ oral surgery. There will still be a need to a greater number of Oral Surgery Consultants (NHS and academic) to undertake the most complex surgery, offer leadership, provide education and undertaken research. (Currently only 115 Consultants) This will allow Oral and Maxillofacial Surgery colleagues to focus on undertaking oral cancer surgery, craniofacial trauma and other complex Level 3 work.There should be much greater use of conscious sedation techniques for patients undergoing oral surgery in primary are and secondary care to avoid the need for hospital general anaesthesia services. This would also enhance the quality of care for patients with severe dental anxiety or medical and behavioural indications or because of the complexity of the surgery required. Oral Surgeons will continue to require use of general anaesthesia as appropriate especially for Level 3 work. Much of the facial trauma surgery is currently undertaken by Oral Surgeons, many in Staff and Associate Specialist (SAS) posts.
- There is a need for effective Oral Surgery Consultant led Managed Clinical Networks to oversee the functioning of the specialist pathway.
- Electronic referral management systems should be used with Specialist and Consultant clinical triage decision-making to enable appropriate redirection of patient flow and enable consistent and accurate data describing patient flows.
- Oral Surgery Patient reported Experience (PREMs) and Outcome measures (PROMs) should be recorded.
- Oral Surgery services should be integrated with other health care systems. Those in primary care should be part of Primary Care Networks with General Medical Practitioners, Pharmacists and others. The clinical care delivered should be wider and flexible according to local needs and recognising the high level of professional skills to offer. This may include integration with diabetes, or pain services, for example. Education should include that of professional colleagues in addition to patients.
- Oral Surgeons should be at the forefront of oral cancer identification from clinical examination. This should be given high priority as routine dental care and examination has been interrupted.
- Oral Surgeons should be involved in provision of services for nursing and care home, prisons and other areas providing care for vulnerable adult and also children.
- Oral Surgeons should be present in health environments such that they can offer clinical leadership of integrated teams.
Concerned about Aerosol Generating Procedures (AGPs)?
Me too. They have been on my mind in the last few weeks. So I, like many others, have been seeking this ever-elusive piece of kit. The ULTIMATE mask.
Essential qualities: comfortable to wear, usable with glasses/loupes (and a head light plus a visor if that’s not pushing my luck) and 100% impregnable to THE virus. Unlike Batman’s, it actually needs to cover my nose and mouth.
Desirable qualities: easy to exhale through, anti-fog (what’s the point of loupes if you can’t see through them?) and not too bulky (thus avoiding inevitable head clashes with other team members and the light).
There is also the valve conundrum1. Valve positive masks are not people friendly as the wearer exhales towards the patient. Valve negative masks are not surgeon friendly and result in eyewear steaming up and moisture collecting between the mask and the operator’s face. I generally find it helpful to see what I am doing and I suspect my patients do as well. So not Spiderman’s either.
My first experiment was with FFP2 masks – comfortable and valve-less seemingly without too much fogging up but this led me to suspect the seal was not 100% and, of course, they weren’t much good for AGPs. This led on to two types of disposable FFP3 masks – one heavy duty builder’s type – definitely impregnable but try as I might, my loupes would not sit properly and I’m not skilled enough to operate whilst seeing double. The second FFP3 type was much more comfortable but (small snag) dated to expire in 2016 – helpfully this date had been extended (with a sticker) to 2019 but this didn’t instil huge confidence. And they seemed to pass the fit test so they were reasonably virus-impregnable. Probably. And I could wear loupes with them – but they did have a valve.
The final respirator mask I have tried is really hard core. There ain’t nothing getting through this baby. I do sound alarmingly like Darth Vader though and breathing isn’t easy. Not terribly reassuring for my poor patients. It also has a valve – which needs to be covered by a surgical mask – producing moisture collection underneath and an interesting aqua-plane type effect whereby the mask slides around on my face. The seal holds though but it does need removing and cleaning at regular intervals. Defeating the point, perhaps?
All this on the assumption that picking up a surgical handpiece equates to an Aerosol Generating Procedure (AGP). Looking through the literature, I found a good summary from NHS Scotland2. High speed dental drills are categorised as AGPs as are ‘upper ENT airway procedures that involve suctioning’ but no mention of surgical handpieces or slow speed drills. So the FFP2 should be OK for Oral Surgery. Probably. Maybe. Hmmm – I think I’ll stick to my respirator for now.
Rebecca Hierons, Immediate Past President of BAOS
The necessity for strong leadership has never been greater, with lack of COVID-19 related dental evidence and an unprecedented clinical and political challenge. Working out-of-programme (OOP) this year and having the opportunity to work in the centre of NHS England and Care Quality Commission, during the COVID-19 pandemic, has given me much to reflect on. I outline two key lessons below:
During this pandemic a lack of quality evidence has presented policy makers, guideline developers and specialty associations with a dilemma – particularly when evidence-based dentistry is gold standard1. This has resulted in consensus-based guidelines and recommendations, as evidenced by the recent Cochrane Oral Health Rapid Review of International sources on re-opening dental practice2. The threshold of desire for evidence-base, although honourable, must in certain circumstances be reduced. In my opinion, this pragmatic approach, in emergency planning, is necessitated and will undoubtedly have saved lives of patients and colleagues.
Unintended consequences of actions
With every action there is a reaction. Fear of burdening the NHS and contracting COVID-19, compounded by public health messaging to ‘Stay at Home’, has impacted A&E attendances3. At times our actions may cause unintended consequence. It is important we reflect on these experiences to help prevent, mitigate and promote any future reoccurrence.
This unprecedented time has caused much concern and upset, however, we must learn from our unique experiences and embrace the opportunity to better shape the future of our profession.
1. Richards, D., Lawrence, A. Evidence Based Dentistry. British Dental Journal. 1995 Oct 7;179(7):270-3
2. COVID-19 Dental Services Evidence Review (CoDER) Working Group. Recommendations for the re-opening of dental services: a rapid review of international sources. Cochrane Oral Health. 2020 https://oralhealth.cochrane.org/sites/oralhealth.cochrane.org/files/public/uploads/covid19_dental_reopening_rapid_review_07052020.pdf. Accessed online 16th May 2020.
3. Academy of Medical Royal Colleges. Patients and the public must continue to seek medical help for serious conditions during this COVID-19 pandemic. 2020. https://www.aomrc.org.uk/wp-content/uploads/2020/04/200407_patient_public_seek_medical_help_statement.pdf. Accessed online 19th May 2020.
President’s March 2020 Newsletter
The Oral Surgery Response to Coronavirus Disease (COVID-19).
Keep Calm and Carry On?
The iconic ‘Keep Calm and Carry On’ poster, first designed by the British Government in 1939, was based on the words of Sir Arthur Newsholme, Principal Medical Officer responsible for the whole of Britain. Sir Newsholme recommended that no action be taken against the 1918 flu pandemic as munitions factories and public services needed to remain open to help with the war effort. He made a huge mistake. Contrast with Dr James Nivin, Medical Officer of Health for Manchester, who recommended that schools and cinemas be closed to reduce people’s proximity to each other and published leaflets that were displayed around the city, advising residents on how to reduce the risk of becoming infected. Niven meticulously analysed statistics to be as informed as he could be so that he could give the people of Manchester the best advice on how to prevent exposure to the Flu. He saved countless lives.
Whilst it may be important to remain calm in adversity, and Oral Surgery training prepares us for this in the operating theatre, we need the best proactive evidence-based advice and risk assessment for managing our patients and ourselves in response to the coronavirus (COVID-19) pandemic. Countries are responding to the global pandemic in very different ways, from strict control over movement of individuals, to more liberal approaches, and reacting at very different speeds. All strategies are based on the best scientific evidence, but interpretation differs according to regional philosophical, social, political and economic ideology. Some have gone for containment with some success whilst others like the UK and others in Europe, the current epicentre of the pandemic, that are accepting delaying the inevitable spread of disease in their populations. China has used unprecedented containment and social distancing measures that would not be acceptable, and could not be readily be replicated in other countries, especially democratic ones with institutional protections for individual rights.
Singapore, Taiwan and Hong Kong have brought outbreaks under control without forced quarantines and containment and are now seeing the number of new cases reduce. Singapore authorities undertook intensive efforts to trace the contacts of patients known to be infected. Hospital staff went to great lengths to interview patients about their recent whereabouts; when information was unclear or unavailable, the Ministry of Health retrieved additional data from transport companies and hotels, including consulting CCTV footage.
Hong Kong has taken a different approach more focused on preventing transmission within the community. Local clinicians were asked to report to the city’s health authorities any patient with a fever or acute respiratory symptoms. The Universities of Hong Kong and Singapore closed in January for four months, including their Dental Schools and Hospitals other than for emergency care. South Korea, probably one of the most technologically advanced countries in the world, has gone like others for early identification through widespread testing. This is based on a belief that asymptomatic individuals are infectious.
The UK NHS advice has been to continue with general dental care using routine personal protective equipment (PPE) unless a patient has symptoms. Patients who have symptoms should not be attending for dental treatment and should self-isolate. Patients who are symptomatic and/or who have COVID-19 and need urgent dental care that cannot be delayed should be treated with clinical staff using appropriate PPE by a service equipped to deal with them. In this scenario aprons, gloves and a fluid repellent mask should be used whilst assessing and treating patients. Gowns, gloves, FFP3 masks and eye protection should be used whilst performing aerosol-generating procedures.
China has had a different approach for general dental care as described in a recent paper by clinical academics at Wuhan University School and Hospital of Stomatology (1). I understand from direct communication with one of the authors, Fang Hua, that all provinces, one by one, initiated their, ‘Level 1 Response to Public Health Emergencies’ around 20th January when it was determined that COVID-19 was spread by interpersonal transmission via respiratory droplets and contact. This included the suspension of all routine dental care and provision of care for emergencies only. As new cases have reduced dramatically in most provinces, the provision of routine dental care is gradually getting back to normal. Finding ways to reduce aerosol for emergency patients is described in the paper. Patients with serious oral and maxillofacial injuries were admitted and a chest CT was used to exclude suspected infection rather than await the time-consuming RT-PCR test.
The Chinese view has been that due to the unique characteristics of dental procedures, where a large number of droplets and aerosols could be generated, the standard protective measures in daily clinical work are not effective enough to prevent the spread of COVID-19, especially when patients are in the incubation period, are unaware they are infected, or choose to conceal their infection.
Splatters created during oral surgery procedures, are like aerosols, also contaminated by respiratory pathogens. The UK view is that asymptomatic patients should be treated as usual with standard PPE. What therefore is the evidence for transmission from asymptomatic patients? There are now reported cases of transmission of infection during the incubation period (2) but there is little information about the quantification of the viral shedding during the incubation period or subclinical infection compared to symptomatic infection. It is therefore difficult to assess the risk of treating asymptomatic patients.
The National Health Committee of China has stated in relation to COVID-19 that ‘Exposure to high-concentration contaminated aerosols in a relatively closed space for a long time, may lead to transmission of COVID-19 via aerosols’. The Chinese recommendation to minimise aerosol-generating procedures during dental procedures seems sensible and a paper produced during the SARS outbreak provides detailed suggestions on this (3).
It is important that Oral Surgeons act professionally and with compassionate non-judgemental attitudes to patients in this viral pandemic as we have learned from previous experiences such as the HIV/AIDS outbreak (4). We need to be confident in the clinical care that we provide and knowledgeable of the precautions to prevent cross infection. The general public would expect this of us. We are familiar with risk assessment and surgical practice to reduce the prevalence of occupational related-health problems such as percutaneous injury and hepatitis B and hepatitis C. Interestingly a systematic review has shown that we are actually more concerned about musculoskeletal disorders! (4)
In my personal opinion it would be sensible to use gowns, gloves, FFP3 masks and eye protection for all oral surgical patients whether symptomatic or not to achieve maximum protection. In hospital and most primary care settings this standard is not difficult to achieve. I would be anxious to provide any type of dental clinical care without the appropriate PPE and this is a real issue given the huge increase in demand. I have made the decision to close my own Barts and The London Dental School at QMUL to patient care undertaken by students at the end of today. Non-clinical teaching will continue until the end of this week and then move completely to on-line teaching with review in six weeks time. Students are at higher risk of occupational incidents and our stocks of PPE are low. Staff who themselves are at risk because of medical compromise are being advised to work non-clinically from home until the pandemic ends.
Planning for our own local service is important. I set up a, ‘Covid-19 Planning Team’ some time ago with responsibility for collating information to inform our decision-making. Views and advice have been sources from the University, Dental School Council, Medical School Council, General Dental Council, affiliated Hospital Trust, WHO, UK National Health Service (NHS), Public Health England (PHE), NHS England, Health Education England and more. We need to be confident about our PPE, communication and expectations so that we can look after ourselves so that we can look after our patients. If you are in hospital practice then you will be already receiving information on how to prepare in your own setting.
The next few weeks will bring huge changes to UK healthcare provision as our NHS struggles to cope. The UK delay approach is an attempt to manage Covid-19 disease to better match capacity of services. It seems that ‘flattening the curve’ is not intended to change the ‘area under the curve’ and so the pandemic can be expected to with us for many months. Recently retired staff are likely to be brought back into the workforce and clinical academics, including ACFs and ACLs, are likely to be providing full-time clinical service. Elective hospital surgery will be cancelled so that theatres can be transformed into ITU wards, private sector hospitals will be used by the NHS, and it is expected that hotels will transformed to provide additional clinical capacity.
It is clear at this time that there is huge need for research evidence in our world of oral surgery to develop consensus on infection risk and research evidence-based infection control guidance specifically for dentistry and our speciality. There has been a proposal for a Clinical Oral Microbiology Hub and Spoke Service to support healthcare professionals. I support such a proposal! The UK dental specialty of Oral Microbiology needs development to ensure contingency and succession planning. The speciality would also have a role in diagnosis, surveillance and the management of orofacial infections. Some dental professionals and Oral Surgeons may have social and psychological anxieties that prevent them from providing clinical care and this can be alleviated by good underpinning science.
We are still in the ‘calm’ before the storm so take a leadership role and get planning if you haven’t done so yet! It’s going to be a while before Oral Surgery, our health services, and possibly society, returns to normal, probably a new normal. We need to engage in a spirit of collaboration, looking out for each other, our patients, especially our vulnerable patients, our staff and our referrers. We also need to take seriously our own mental health and wellbeing and plan to support others in our oral surgery community. Keep calm, but plan ahead, and use appropriate personal protective equipment.
This paper expresses the personal opinions of the author.
Professor Paul Coulthard, BAOS President
16 March 2020
- Meng L, Hua F, and Bian Z. Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine. Journal of Dental Research: 2020; DOI: 10.1177/0022034520914246.
- Rothe C, Schunk M,Sothmann P, Bretzel G, Froeschl G, Wallrauch C, Zimmer T, Thiel V, Janke C, Guggemos W, Seilmaier M, Drosten C, Vollmar P, Zwirglmaier K, Zange S, Wölfel R, Hoelscher M. Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany. N Engl J Med 2020; 382:970-971 DOI: 10.1056/NEJMc2001468
- Li RW, Leung KWC, Sun FCS, Samaranayake LP. Severe Acute Respiratory Syndrome (SARS) and the GDP. Part II: Implications for GDPs. Br Dent J, 2004:197,130-134.
- Coulthard P, Tappuni AR, and Ranauta A. Oral Health and HIV: What Dental Students Need to Know. Oral Diseases. In Press.
- Moodley, R., Naidoo, S., & Wyk, J. V. (2018). The prevalence of occupational health related problems in dentistry: A review of the literature. J Occup Health, 60(2), 111-125. doi:10.1539/joh.17-0188-R
- Having the conference venues close together to minimise travel
- Encouraging admin and council staff to travel by rail to reduce our carbon footprint
- Going paperless- all conference information including certificates and event tickets will be released via our conference app – further info coming soon!
- Recycling prior to and following the conference
- Asking attendees to confirm their attendance at the social events – last year some seats at the formal dinner were not taken up, which resulted in food waste
We look forward to seeing you all soon!