Practice Closures, Redundancies, Layoffs, Threats, Bullying, Salary Cuts

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We live exceptional times. We all live exceptional times, not just us dental professionals. But it might feel like we are alone in this, when the measures we must take are drastic and have huge impact on us.

At times like these, I would hope to see solidarity, compassion and charity amongst people more than ever before. The rich giving help to the poor. The healthy giving help to the sick. This is already happening to some extent.

I am happy to notice that the healthy are helping the sick – offering to do food shopping for them etc. But when it comes to finances, it seems to be so, that only the poor is giving help to the poor, giving out form the little they have even though they are also struggling. Is this how it should be?

Now would be the time for the rich to spend money, keep the small businesses running, help out the single parent families. A small deed might mean a world to someone.

How about in dentistry?

I recently asked dental professional tell me how the coronavirus have affected their practice. I also did some research on internet forums and facebook groups. It’s quite fragmented when it comes to the policies and procedures the dental practices have taken.

Most likely the trade unions are to blame. They have not provided adequate and prompt advice to their members. Matters around coronavirus have developed faster than the responses from professional bodies in different countries (BDA, ADA etc.)

This has forced the dentists to take the matters in their own hands. Some dentists have decided to close their practices for couple of weeks. Some have concentrated on seeing patients that need urgent treatment. Some have not done any changes.

Behind these decisions are many difficult questions. How about the supportive staff? Can they be allowed to work? What should be done, so that they are protected from the virus? Surgical or N95 masks? Full face visor or safety glasses? Are they taking their holiday leave if the practice closes. Or are they laid off with less money or no money at all?

And even more serious questions. How long will this epidemic last? Will my practice survive this? The bills keep on coming despite the circumstances.

These questions do not necessary have a right answer. Maybe that is why there has been both overreactions and underreactions.

Ugly side of our profession

I have written about dental practice’s hierarchy in my previous posts (part I, PartII, Part III) and how between different professions in dentistry there is not always equality. This whole business with coronavirus has raised again that questionable side of our profession where the dentists are deciding for the nurses in the matters of health.

There’s been downright threatening about nurses loosing their jobs if they didn’t comply with the dentists’ decisions to keep the practice open. There’s been bullying in a form of shouting (there should be no shouting at any workplace). Some dentist let the nurse take a time off but without any salary. The dentists themselves carry on working.

What I am afraid of is that our profession is not using this downfall to strengthen the teams they work in, but to increase the division between different dental professions. Now would be the time for solidarity, compassion and understanding. From everyone. But it cannot be one-sided.

Single-Use Masks

Some practices have found creative ways to guarantee that they won’t run out of face masks. Some have told they autoclave used masks that do not look soiled. Some have told they use the same mask all day long. Some think that surgical mask will protect you. Or wearing a surgical mask on top of the other will provide extra protection.

Thankfully all the above are just isolated cases and majority of the practices follow the standard of care we are supposed to. But just to remind everyone – single-use means single-use. The mask should be changed after each patient and disposed carefully. Used mask should not be autoclaved under any circumstances.

Some facts. Even though the surgical mask filters the airborne viruses, there is leakage from the sides of the mask when person wearing the mask inhales. So airborne viruses will enter through the sides. Therefore N95 masks are the only ones that provide close to 100% protection from the airborne viruses and all the dental staff should wear N95 masks when they perform treatments that produce aerosols (remember that even air-water syringe does that). Even if you are treating only seemingly healthy patients, you will never know if the patient has contracted the virus and not showing the symptoms yet. He is nevertheless spreading the virus already. That is why dental staff should wear at least N95 masks, full face visors, protective disposable coat and a hat for all procedures that produce aerosols.

Have look at this link, where the difference between the surgical mask and N95 mask is explained in detail.

We are in this together

It’s thankfully not all that gloomy. There are stories about practices pulling together. Doing the right thing. Everyone in consensus. That’s how it should be. If it isn’t, somebody is not listening. Somebody is using one’s power in nonconstructive way.

Money is important to everyone. To the dentists, the hygienist and the nurses. Money is probably the reason why different views collide. We all are worried about financial effect of the situation. Everyone should be prepared to downsize in life style to get over this difficult period. Owners of the practices will need to make difficult decisions over salaries. Hopefully these decision are made with solidarity and respect. I know stories of restaurants where they have started to provide take away food with delivery and all the revenue they make, goes towards the employee’s emergency fund.

If the owner or a dental practice has been wise and farsighted, he has put some money on side for emergencies. Hopefully this money covers the bills and if there’s any leftover, it is used to help the employees. By doing that, practice owners make sure their employees stay loyal to the practice and highly motivated towards the work after this difficult period has passed. Motivated and loyal staff is a great asset to the practice and the patients will notice the good vibe and spread the word. So by taking care of the employees financially, you are actually putting money into marketing. That if anything is a win-win situation.

BDA Steps in, Finally

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It took a tad too long, but it is here. The official advice from the British Dental Association (BDA).

BDA Sunday 22 March 2020

10:35 BDA issues urgent advice to dentists
In all four nations of the UK, governments and officials have issued recent advice in relation to the provision of primary care dentistry. This clinical advice has reflected the UK Government’s developing position in relation to increasing social isolation, reduction in use of public transport and use of health services, and also growing unease, as infection levels grow, about the potential for spread of COVID-19 from asymptomatic patients.

Official advice across the UK is not exactly the same, but there is a consistency in guidance that there should be a reduction in the amount of routine dental activity, particularly in respect of vulnerable groups and importantly that staff and patient exposure to potential infection should be reduced by avoiding all aerosol generating procedures wherever possible.

Appropriately, all dentists should exercise their own clinical judgement, taking into account their own practising circumstances. However, given the high proportion of patient interaction in dentistry that has the potential to involve aerosol generation, the BDA believes that for most practices it is likely that compliance with the guidance of the various UK administrations will mean a significant reduction in routine clinical activity. Indeed, for many practices, the practical consequences of the guidance will mean ceasing routine care entirely, given the difficulties of identifying in advance patients who will not need aerosol generating procedures. The BDA supports dentists and practices choosing to stop regular patient treatment.

We believe that current guidance should be more explicit given the continuing spread of the virus and uncertainty around asymptomatic transmission and the associated risks. Given this uncertainty, the BDA recommends that no aerosol generating procedures are undertaken on any patient without appropriately fitting FFP3 masks, other required protection equipment and protocols.

Further, given the uncertainty and reflecting the practical consequences of the current official advice, we recommend that practices cease routine dentistry and operate an advice and emergency service only. Consistent with Government advice to limit social contact, face to face contact should be kept to a minimum but telephone advice should remain available during normal hours. This service will be important for patients, particularly until fully fledged emergency provision is in place. Each practice should make its own risk assessment of what is safe and what can be delivered by way of an ongoing emergency only service.

The situation is changing rapidly and it may well be that as the pandemic evolves emergency only treatment and patient contact will only be deemed appropriate in particular setting and temporary practice closure may become mandatory.

As things stand, the chance of advanced PPE equipment, protocols and training being widely available to avoid this seems unlikely, with resources appropriately being directed to intensive care. In any case, the development of Government advice around social isolation has the potential to further limit the availability of routine care.

The purpose of this advice is to give maximum protection to dentists and staff but it remains an individual practice decision as to what level of service continues to be provided on the basis of rigorous risk assessment.

Again there will be variation across and within UK countries, but local discussion should be taking place around the provision of NHS urgent dental care, particularly as the amount of routine care decreases. Arrangements for the provision of emergency care will become increasingly important if and when the country moves towards further social isolation and further lockdown of normal activities. Dentists involved in urgent care in specialist centres will require full personal protective equipment including FFP3 face masks.

Clearly, a reduction in clinical activity will have financial consequences for practices and for associates. The BDA is acutely aware of this and we continue to make the case forcefully to all administrations that support is offered to protect dentists’ NHS income and that this protection extends to associates. We are also conscious of the impact on private dentistry and are arguing to government that private practices should have appropriate access to the range of wider financial support being made available to business across other sectors.


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