In my Newsletter in early January 2020 I highlighted our BAOS Mission Statement, ‘Excellence in Oral Surgery through education, training and research for better patient care’ and the enthusiasm of BAOS Council to continue during 2020 to support Oral Surgeons and their teams in delivering the highest standards of care for their patients. That delivery of surgical care has been harder than we could have imagined. With the suspension of routine dental care to mitigate coronavirus transmission by close contact and aerosol, and the suspension of routine surgery to enable NHS capacity for COVID-19 patients, the face of oral surgery care has changed. My last Newsletter in March I discussed our early oral surgery response to the COVID-19 pandemic. We have experienced and learned a lot since then!
The provision of emergency and urgent care is a moral imperative. Patients with facial trauma, spreading infection and swelling that compromises the airway have typically presented directly to Accident & Emergency departments or been immediately referred by a dental practice. This service has continued and many Oral Surgeons have provided care to these patients. Urgent surgery has also been undertaken in primary and secondary care with many oral surgeons contributing. There are reports of patients not attending Accident & Emergency departments for fear of contracting COVID-19 and problems with access to urgent dental care because of PPE shortages. There have also been capacity issues around COVID-10 testing for dental professionals.
The BAOS Council recommended cessation of routine care and the use of appropriate PPE with our first website advice on 16th March. We received messages of gratitude for the prompt advice from many individuals in the UK and also around the world and from several professional bodies. We recommended the use of gowns, gloves, FFP3 masks and eye protection for all oral surgical patients whether symptomatic or not to achieve maximum protection at a time when the NHS view was to use routine PPE unless a patient had symptoms or close contact history supposing that patients were not infectious if asymptomatic.
BAOS Position Statements
We went on to produce a series of COVID-19 Position Statements jointly with BAOMS about PPE and respirators, urgent care and domestic violence and abuse, that I trust were helpful. We also highlighted a limited number of articles relating to urgent care, analgesia and radiography, and the SDCEP and Cochrane Oral Health COVID-19 resources. We have all been overwhelmed with guidance from so many sources so we resisted publishing guidance from elsewhere, conscious that much has been of poor quality. Importantly we published ‘Information for Patients during the Pandemic’ on 6 April. This is a novel virus so research evidence is scanty but growing fast. Our Council’s agreed view was based on rapidly reviewing evidence as it appeared and also incorporating the learning from colleagues ahead of us in Wuhan, Hong Kong, Singapore, South Korea as well as Europe.
Many countries, including our own, moved to telephone and video consultations but we have learned, not surprisingly, that the absence of clinical examination and ability to offer an accurate diagnosis and comprehensive care has been uncomfortable. The loss of screening for caries, periodontal disease, oral cancer and others by the general dental services will doubtless have allowed disease progression, pain and suffering. There are of course, some advantages of remote consultations that we will want to keep!
BAOS has contributed to the national response to the COVID-19 pandemic with written submissions and discussion with NHS England and PHE. We were invited to review the draft changes to PPE for the CMO Clinical Advisory Group via the Academy of Medical Royal Colleges. We were invited to contribute the Restorative Dentistry COVID-19 guidance. Our views have not always been accepted but we have continued to lobby. We were anxious about the encouraged avoidance of surgical extractions, as care to avoid surgical extraction is always an aim of tooth removal, but this cannot always be reliably predicted. Avoidance of tooth removal for concern of becoming a surgical procedure would inevitably encourage inappropriate use of antibiotics and analgesics that can predictably lead to spread of infection. A surgical handpiece causes aerosol in addition to splatter and both are a health risk to the surgical team. Whilst it was acknowledged that a respirator should be part of the PPE when using a surgical handpiece the shortage of these would have inevitably driven the need to restrict surgical tooth removal.
I was invited as President of BAOS to present at a webinar about PPE by the BDA hosted by the Royal Society of Medicine. I will shortly be speaking at the European Association of Paediatric Dentistry online conference about the impact of COVID-19 on dentistry. Richard Moore, BAOS Council Member, has presented an RSCEd webinar, ‘Surgical Dental Procedures in a post-COVID-19 world – what is new?’.
Education and Clinical Research
The COVID-19 pandemic has resulted in the suspension of University face-to-face undergraduate and postgraduate teaching, with rapid transfer to on-line teaching arrangements and assessment. All simulation-laboratory instruction and clinical teaching has been suspended, as has Clinical Research. The work involved in making such sweeping changes to education has been immense for our clinical academic colleagues. The Higher Education sector is anticipating financial pressure in the autumn and some univerisities are mitigating the risk with voluntary severance schemes, my own included. The economic consequences have already impacted clinical general dental practice and has increased the financial risk for primary care oral surgeons.
It will be difficult to ascertain the full impact of the disruption to dental services, education and research but it is likely to be substantial. The immediate focus is now on return to routine care provison with likely longer-term permanent changes. The very helpful, ‘Recommendations for Oral Surgery during the recovery phase of the COVID-19 pandemic’ was published in June. The development of these guidelines was led by Judith Jones, BAOS Council Member, on behalf of the Faculty of Dental Surgery, RCS England, and Tilly Loescher on behalf of the Association of Dental Hospitals and in collaboration with the BAOS.
Richard Moore, Divya Keshani and I have overseen the BAOS Survey of its membership to understand the impact of COVID-19 on their practice and provision of care for patients. Re-deployment clearly caused initial anxiety for some and PPE shortages cause ongoing concern and stress.
There were hospital visits last year in preparation for the, ‘Getting it Right First Time’ (GIRFT) report. The GIRFT visits to surgeons, clinicians, support staff and managers were invaluable in highlighting areas of persistent variation and in making recommendations that were about to be published as the COVID-19 pandemic reached the UK. BAOS had contributed to the report and we were invited to contribute again as the NHSEI wanted to incorporate specialty responses and 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.
Oral Surgery Trainees
Our trainees have been involved in urgent dental care delivery and around 60% have been re-deployed to support the medical response to COVID-19. This is a new world for all of us but is particularly difficult for our colleagues at this stage in their careers. There has always been a degree of uncertainty about oral surgery career progression but this pandemic has added an additional level of anxiety. More positively most have embraced the opportunities of change.
Our September 2020 Annual Scientific Conference at the Assembly Rooms Edinburgh has been postponed until 4-5 March 2021. The majority of the members that responded to feedback requested a trial two full days, rather than the usual 2 1⁄2 days conference, with slightly shorter presentations. This will likely be more appreciated than had been anticipated as with a depressed economy and building waiting lists, study leave requests may be more difficult. Put the date in your diary!
The BAOS Councils’ mission is to serve our surgical community and will continue to lead our specialty in the UK and contribute to the support of oral surgeons worldwide. We can be proud of membership that is supportive of patients and of each other. Please also note that we now have an Instagram account in addition to our Facebook and Twitter presence. Please follow and share!