RCSI Faculty of Dentistry ASM: ‘Dentistry in the new decade’
ASM 2020 was chaired by Professor Albert Leung, Dean of the Faculty of Dentistry, RCSI, and delegates were welcomed by Professor Cathal Kelly, CEO/Registrar at the RCSI.
Speakers included Dr Martin Foster of Dental Protection, Professor Anthony Roberts, of University College Cork, Professor Alastair Sloan, of Cardiff University, Dr Radi Masri, of the University of Maryland’s School of Dentistry, Dr Saorise O’Toole, of King’s College London, Professor Paul Coulthard, of Queen Mary University London, Dr Suk Ng, of King’s College London, Professor Jo Frencken, of Radboud University, Nijmegen, Professor Sam McConkey, of the Royal College of Surgeons in Ireland, Yangfang Ren, Professor in the Department of Dentistry at the University of Rochester Medical Center, Dr Paul Quinlan, an examiner for the Royal College of Surgeons in Ireland and Professor Nicola Innes, of Cardiff University.
The Edward Leo Sheridan Lecture 2020, Dentistry in the New Decade: The Impact of COVID-19 Upon Oral Health Care was delivered by Stephen Porter, Director and Professor of Oral Medicine at UCL Eastman Dental Institute. Professor Porter set his lecture in the wider context of the challenges facing society; poverty, inequality, hunger and global warming. But he focussed on the implications of COVID-19 on oral health.
As he spoke, there had been more than 58,000 infections in Ireland and more than 895,000 in the UK. Deaths stood at 1,885 and 45,000, respectively. Across the world, the figures were 43.5m and 1.16, respectively. It does not just cause pulmonary disease, he said, but can affect any part of the body with both short and, potentially, long-term consequences, some of which may impact on oral health.
Professor Porter detailed the potential effects of COVID-19 on the body, the medical factors increasing the risk of death, as well as the ethnic and socio-economic factors that should be considered. He described the Irish, UK Government and devolved administrations’ responses to the pandemic, the economic implications, and the impact on the healthcare system. Health workers who previously provided dental care had been reassigned. Public health services previously provided by the NHS have shifted to the private sector. All of these will have an effect on oral health, said Professor Porter. Before considering this in detail, he described the potential of vaccines and the challenges in making them effective, as well as the role of drugs in mitigating the disease.
The impact on oral health
Professor Porter detailed the cessation of dental practice across primary, secondary and tertiary care, the transfer of patients to telephone triage, and the establishment or urgent dental care centres for the management of significant issues. There was some realignment of secondary and tertiary care, but they worked to guidelines that were “not notably evidence-based,” he said. Guidelines were developed to provide symptomatic relief and to identify life-threatening illness. Similarly, guidelines for this were not based on strong evidence and relied heavily on the use of analgesia and anti-microbials. PPE supply was an issue, and the regulatory responses were “not notably fast”. Clinical care suffered, said Professor Porter.
In terms of the impact on clinical staff, practices were closed – and, in some instances, employees were able to be furloughed. But the support from Governments for practices and clinical staff was limited. Some staff were able to transfer to provide support for hospital intensive care and theatre teams. “In the hospital I work in, we had a consultant orthodontist assisting in the delivery of babies,” said Professor Porter. “They found it remarkably interesting. The obstetricians, initially, found it a little bit challenging, but then remarkably rewarding. And the babies and families were happy. Everything went well.”
Professor Porter said it was difficult at that point to ascertain the effects on oral health; there was not enough epidemiological data. But he added: “It is estimated that there were around 15 million check-up and treatment sessions lost in the UK and many thousands of exodontia procedures on children were postponed.” His lecture reflected the concern at the time among dentists about their ability to return to practice at anywhere near a pre-COVID-19 level of activity and the associated implications in terms of delayed treatment and missed disease. The financial sustainability of practices, and the livelihoods of dental professionals, was also a concern, he added.
While prescribing analgesics and anti-microbials provided short-term comfort to patients, there was the long-term risk of them developing anti-microbial resistance. Tele-dentistry had allowed some contact between practitioners and patients, but every speciality had encountered challenges, said Professor Porter, because of the concern around aerosol generating procedures (AGPs). The incidence of oral disease progression was likely to increase. In oral medicine, where AGPs are not used, Professor Porter said that patients were presenting with facial pain or burning mouth syndrome because, he suggested, of anxiety caused by the pandemic. “What you can conclude is that all aspects of healthcare have been compromised and it is likely to be for some time,” he said.
Professor Porter described the concern around AGPs as a “major roadblock”, but that there was no strong evidence that aerosol spread of COVID-19 was likely to be common in a dental setting. The publication by the Scottish Dental Clinical Effectiveness Programme (SDCEP) of its ‘rapid review’ on AGPs had provided “some hope”. Now there were some more manageable clinical guidelines, he said, based on a number of principles – on the use of three-in-one syringes, high-velocity suction and rubber dams, for example – along with the possibility of reducing fallow time to 10 minutes, which will allow more patients to be seen. A resurgence of COVID-19 and renewed restrictions around social distancing could still have an impact, however. Faltering moral and rising anxiety among staff could see them lost permanently to the profession. There also remained the question of who would pay for the additional measures necessary for practices to see patients in-person.
The professor also highlighted the continued risks to the most vulnerable in society and those who suffer inequality. “If anything has been made clear in all of this it is that the COVID-19 pandemic has exacerbated socio-economic and ethnic inequalities and it will undoubtedly worsen oral healthcare,” he said. “Therefore, we need to quickly work out how we can establish good oral health care and prevent oral disease for as many people as possible, particularly those who suffer inequality.”
Education and research
Teaching in university and clinical education stopped with lockdown, said Professor Porter, though institutions did switch to online learning and there has been a gradual return to clinical teaching, but only in some dental schools around the world. There was limited or no graduation of dental students in 2020. In the UK, Brexit and the morale-sapping effect of COVID-19 combined to have a “choking” effect on people entering the profession, said Professor Porter. Nonetheless, the delivery of online dental education has been advanced in a matter of months, as opposed to years; a phenomenon experienced in other sectors, also.
In terms of research, the bulk is carried out by universities and – as it was with teaching – it ground to halt with lockdown (aside from that associated with COVID-19). Clinical trials stopped. Research has restarted, but there are delays in outputs and additional costs associated in restarting. Research income from charities will fall because their income has suffered as a result of the pandemic. Is there an upside, however, Professor Porter asked: “Without doubt, university research has significantly influenced our understanding of COVID-19 and helped improve the return of oral healthcare – for example, the work undertaken in Scotland was all undertaken by university staff.”
Professor Porter said that the pandemic had encouraged cross-sector and trans-national cooperation and had raised the profile of oral health care professionals through their appearance on webinars and in the media. There may be future research opportunities in terms of how COVID-19 has changed oral health care, he added. Though he was critical of the variation in national responses, the messaging from public bodies on dental practice, and the lack of forward-thinking around dentistry in discussion papers published in response to COVID-19.
The future of oral health
In conclusion, Professor Porter said: “While COVID-19 may disappear, or become manageable, other pandemics may come along. So, anything we learn now may have value for the future. Oral health care is important – for life and for general wellbeing. It must be protected. The burden of oral disease lies in people who are low income, who are marginalised and who are in vulnerable groups. Therefore, there is a need to target those groups. And lastly, while the load of oral disease might lessen over time, the nature of oral disease will continue to change as people live longer, and disease prevention gets better and new medicines come along, which may impact upon the mouth or upon the delivery of oral health care.
“What should we do? What are the actions that need to be considered? We do need to look back carefully to learn and influence our leaders; we need to provide them with accurate, relevant information, telling them what has gone wrong, telling them what will work for the future. Leaders need to engage with policymakers in a timely fashion that places people at the centre, particularly placing the people who are vulnerable to ensure they receive effective preventative care and good care of active oral disease.
“Research must be focused upon the questions which are burning, which are rate-determining for COVID-19, not the superfluous ones. With regard to education, we need to maximise the use of technology. But we also need to realise that learners are not fools; that if we are going to generate webinars they need to be of high quality. We need to ensure that the information we pass to oral health care providers ensures that patients are better treated. We need to maximise technology to enable people themselves to change their oral health. The prevention of common oral disease should remain a priority. If plaque related caries, gingivitis and periodontitis is prevented, then there’s less of a need for a patient to acquire an invasive dental procedure.
“Governments must address the issues of deprivation and inequality. Dentists cannot do that. Medical people cannot do it either. They can make representation to governments, but only governments can truly change deprivation and inequality. The research we do should be targeted to key issues with respect to COVID-19 or anything else that is of major oral health need. Education must provide knowledge to ensure appropriate action by health care providers. We must remember that oral health care has changed because of COVID-19. But we must ensure that going forward, oral health care is better than the past.
“Finally, here are some phrases from Plato which, for me, summarise what is happening and what we should do. ‘Wise men speak because they have something to say; Fools because they have to say something’. Be careful of webinars and be careful of poor reviews. They need to say something positive that helps you and in turn helps your patients. ‘The measure of a man is what he does with power’. The leaders of dentistry need to ensure that they tell the policymakers that change is needed. ‘Necessity is the mother of all invention’. You, as an oral health care provider, as a patient, as a member of the public may have a solution to a problem; ensure that you tell others about it. It is important to realise that COVID-19 is a pandemic. We have had pandemics in the past. And we will probably have pandemics of the future. The changes we make now will benefit others in the future. Let us make the most of that opportunity.”
Paediatric dentistry – looking ahead
Dr Dympna Daly qualified from Trinity College Dublin in 1982. She completed a master’s degree in paediatric dentistry at the University of Minnesota in 1989 and was the recipient of the Hatton Award for her thesis on prenatal fluoride. On her return to Ireland, Dr Daly worked part-time teaching at Dublin Dental Hospital and established her private practice in Galway City. Some brief extracts from Dr Daly’s ASM 2020 presentation:
- “One of the nicest aspects of working in paediatric dentistry is that we get the opportunity to look after the oral health of babies and young children as they move through quite dramatic stages of growth and development. And it really is at this young age that we have the best opportunity to instill in them the best of oral health and primary prevention.”
- “We know that for good oral health, we have to begin early – by six to 12 months of age. We can’t depend on the babies to ring up and make an appointment. So, our focus is on parents and caregivers to try and ensure that they’re aware and know to bring their children to see us around the time that the first primary tooth erupts. Preventive interventions in the first year of life are critical.”
- “The Childsmile programme in Scotland has resulted in a saving of millions of pounds for the NHS. It takes only a fraction of the savings to run the entire programme.”
- “A large part of our prevention treatment is the appropriate use of fissure sealants, both for primary and for permanent teeth. We know that these are extremely successful.”
- “The use of nano particles, nano devices and nano robots – there’s some interesting work being done. We’re now seeing applications of these nano materials across all aspects of dentistry. I think we’re going to see some very interesting developments in years to come.”
- “No matter how great our materials, our techniques, or our interventions, we’re really not going to get a handle on this until we have a structured programme allowing us to see [patients] from birth and [for them] to have ongoing access to ongoing oral health care.”