JUNE DENTAL2020 PRACTICE STANDARD OPERATING … Covid book A4.pdf · eept iona circustances suld e is assesse an tis is assessent an te rationae for an eisin taen sld e documente

STANDARD OPERATING PROCEDURES to allow dental practices to reopen. JUNE 2020

JUNE 2020

During the Covid-19 Crisis - Version 3.1

Issued on behalf of the IndepenDent Practice Owners UK

Co-written by Adam Nulty, Vicki Holden and Kris Leeson.

D E N T A L P R A C T I C E S T A N D A R D O P E R A T I N G P R O C E D U R E S S U N N Y S M I L E S D E N T A L P R A C T I C E

Issued on behalf of the IndepenDent Practice owners UK. Co-authored by Dr Adam Nulty, Vicki Holden & Kris Leeson


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COVID-19 Crisis

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index

Issued By : Issued on behalf of

The IndepenDent Practice Owners UK

Authors : Dr Adam Nulty Dr Vicki Holden & Kris Leeson

Introduction 02 Version Control 04 Introduction & Principles 06 Definitions 08 Worldwide employment of PPE 09 Cross Infection Protocol 13 Evidence Base for Protocol 15 What is the Novel Coronavirus 17 Risk Assessments & Patient Screening 18 Vulnerable & Shielded Groups 19 Phase 1 20 Phase 2 22 Phase 3 & 4 23 SOP Cross Infection Control Cleaning Measures 24 Patient Pathways & Treatment 26 PPE 28 Fallow Time Calculator 30 References 34 Appendices 35

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Issued By Issued on behalf of

The IndepenDent Practice Owners UK

Version

Evidence Based Standard Operating Procedures

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Revision date

New version number

Summary of changes

20.5.20 V1 ● Initial Version current stage = Phase 1

26.5.20 V2 ● Move to Phase 2, definition of essential treatment

6.6.20 V3 ● Addition of FGDP, OCDO and BDA references (9,10,11) ● Explanation of services to be provided from 8th June ● Update to definitions of dental treatment/emergencies ● AGPs - further information and link to risk matrix and mitigation



Introduction & Principles

The following Standard Operating Procedure (SOP) details the planning and operating of the following practice during the COVID-19 Pandemic; SunnySmiles Dental Innovations It covers: PHASE 1 - the protocols employed during remote triage system PHASE 2 - the protocols employed when face to face non-AGP urgent care is provided PHASE 3a - the protocols to be employed when AGPs are to be provided for urgent care PHASE 3b - the protocols to be employed when AGPs are to be provided for essential care PHASE 4 - the protocols to be employed when non-essential elective dental care recommences It is expected that the practice may move between the Phases set out in this document depending on the current Alert Risk level in the UK. The COVID-19 Lead is Dr Sunny Chagger Current UK Alert Risk Level - 4 Current Practice status - PHASE 3b will commence on 8th June 2020 Timeline: PHASE 2 commenced on _____________ PHASE 3a/3b commenced on 15/06/20 (when Level 3 PPE/FIT TESTING is available/been completed OR the risk level reduces such that Level 2 PPE is permitted for AGP treatment.) PHASE 3b (To include the introduction of essential treatment in addition to urgent and emergency care). __ PHASE 4 elective (non-essential) care is anticipated to recommence at the earliest on 4th July 2020 or according to the Government directions in respect of the risk level.

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“It is expected that the practice may move between the Phases set out in this document depending on the current Alert Risk level in the UK.”

2020_

COVID-19 & Dentistry

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Novel coronavirus pandemic (COVID-19 Pandenmic) Novel coronavirus may be referred to as: • severe acute respiratory syndrome coronavirus 2, SARS-CoV-2: this is the name of the virus coronavirus disease, COVID-19: this is the name of the disease. Relevant Documents Other relevant documents to be kept in conjunction with this SOP are: PRACTICE COVID-19 risk assessment BDA Risk Assessment NHS COVID-19 guidance and standard operating procedure SCDEP guidance - Management of Acute Dental Problems during COVID-19 SCDEP guidance - drugs for the management of dental problems during COVID-19 Video consultations - process and logins document GDC - GDC guidance on remote prescribing Public Health England -PHE COVID-19 Infection Control Guidance BDA Return to work Toolkit FGDP Implications of COVID-19 for the safe management of general dental practice OCD0 C0575-dental-transition-to-recovery-sop-4-June


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Urgent: Trauma such as dento-alveolar injuries or avulsion of a permanent tooth Oro-facial swelling that is significant and worsening but does not present realistic threat to life Post extraction haemorrhage that the patient cannot control by local measures but does not present realistic threat to life Dental conditions that have resulted in acute and severe systemic illness Severe dental and facial pain: that is pain that cannot be controlled by the patient following self-help advice or the use of appropriate antimicrobials. Fractured teeth or tooth with pulpal exposure Dental and soft tissue infections without systemic involvement/effect. Oro-dental conditions that are likely to exacerbate systemic medical conditions Suspected oral cancer. Essential: Any treatment that ought to be provided to prevent deterioration of a patient’s dental health. Mild or moderate pain: that is, pain not associated with an urgent care condition and that responds to over the counter medications. Minor dental trauma. Post extraction bleeding that the patient is able to control using self-help measures. Loose or displaced crowns, bridges or veneers. Fractured or loose-fitting dentures and other appliances including orthodontics;

If the ulceration is due to part of an orthodontic appliance, patients should be advised to contact their orthodontist for advice. Further information for dentists and patients may be accessed via the BOS website https://www.bos.org.uk

o If the ulceration is due to a fractured tooth or filling, advice includes purchase of a temp filling kit when someone next visits a pharmacy.

● Fractured posts; fractured, loose or displaced fillings. ● Treatments normally associated with routine dental care and bleeding gums.

Definitions Dental Treatments

Emergency (directed to A&E): ● Life threatening emergencies, e.g. airway

restriction or breathing/ swallowing difficulties due to facial swelling

● Uncontrollable dental haemorrhage following extractions that cannot possibly be dealt with within the Practice;

● Rapidly increasing swelling around the throat or eye which causes immediate threat to life;

● Trauma to head and neck to include dental arches that requires maxillofacial services.


Current Worldwide status of the employment of PPE

As of April 2020, all dental care in the United Kingdom has been provided through Urgent Dental Care Centres (UDC) based in regional centres as all Dental Practices are closed on the direct instruction of the Chief Dental Officer of England.10, 11, 12, 13 This document does not aim to repeat the UDC instructions or Standard Operating Procedures (SOPs) which outlining the use of PPE 14 but there is a stark contrast between the PPE employed by these UDC centres and the provision and use of PPE worldwide.15

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Italy

http://www.aio.it/html/uploads/2020/04/DVR-AIO.pdf

http://www.aio.it/html/uploads/2020/04/proposta-linee-

guida-AIO-rev-1.pdf

http://www.aio.it/html/uploads/2020/03/Indicazioni-

Specifiche-Prevenzione-Infezione-Coronavirus-1.pdf

Germany

https://www.bzaek.de/berufsausuebung/sars-cov-2covid-

19/risikomanagement.html

http://dahz.org/wp-content/uploads/2020/04/DAHZ-

Stellungnahme-Corona-20.04.2020.pdf

EU

https://www.ecdc.europa.eu/sites/default/files/documen

ts/Infection-prevention-control-for-the-care-of-patients-

with-2019-nCoV-healthcare-settings_update-31-March-

2020.pdf

Portugal

https://www.dgs.pt/directrizes-da-dgs/orientacoes-e-

circulares-informativas/orientacao-n-0222020-de-

01052020-pdf.aspx

Switzerland

https://www.sso.ch/fileadmin/upload_sso/5_Newsletter/2

020/Covid-19-Positionspapier3-7.pdf

USA

https://success.ada.org/~/media/CPS/Files/Open%20Files/ADA

_Return_to_Work_Toolkit.pdf

Spain

https://www.consejodentistas.es/comunicacion/actualidad-

consejo/notas-de-prensa-

consejo/item/download/1790_197f2dbe5d4c8a1c28ac99fc526

3518b.html

France

https://ordre-chirurgiens-dentistes-

covid19.cloud.coreoz.com/files/COMMUNIQUE%2030AVRIL-

EXTRAIT%20RECO.pdf

Canada (British Columbia only)

https://www.cdsbc.org/Documents/covid-19/Expectations-

Pathway-COVID19.pdf

Australia

http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0016

/581002/Application-of-PPE-in-Response-to-COVID-19-19-

March-2020-V1.4-rev.pdf


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Filtering face piece (FFP3) (Or FFP2 if FFP3 are unavailable) respirators for AGPs Respirators must be: fit-tested on all healthcare staff who may be required to wear an FFP3 respirator to ensure an adequate seal/fit according to the manufacturers’ guidance; fit-checked (according to the manufacturers’ guidance) by staff every time an FFP3 respirator is donned to ensure an adequate seal has been achieved; compatible with other facial protection used – i.e. protective eyewear – so that this does not interfere with the seal of the respiratory protection; regular prescription glasses are not considered adequate eye protection; disposed of and replaced if breathing becomes difficult, the respirator is damaged or distorted, the respirator becomes obviously contaminated by respiratory secretions or other body fluids, or if a proper face fit cannot be maintained; in effect this may mean that respirators may be worn once for dental AGPs and then discarded as clinical waste (hand hygiene must always be performed after disposal); Respirators should be removed outside the dental surgery where AGPs have been generated in line with doffing protocol. In exceptional circumstances it may be acceptable to use a respirator mask for a session. Such exceptional circumstances should be risk assessed and this risk assessment and the rationale for any decision taken should be documented by the UDC Clinician. In the unlikely scenario that FFP3 masks are used for a session they must be shielded from ‘splatter’ with a fluid resistant surgical mask or visor to protect the respirator from droplets; a session ends when the healthcare worker leaves the care setting/exposure environment; PPE should be disposed of after each session or earlier if damaged, soiled, or uncomfortable; PHE and HSE confirm that if FFP3 are not available, FFP2 is acceptable [HSE Face mask equivalence]


“Let’s get back to treating patients safely”

2020_


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“There is a stark contrast between the PPE employed by these UDC centres and the provision and use of PPE worldwide.”

2020_

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Country Mask Gown Non AGP AGP

USA Surgical Masks can be used Dentist’s Discretion

N95/FFP2

Dentist’s Discretion – Use if available

ITALY Double Surgical Mask (unless local guidance states otherwise) FFP2 / FFP3 Yes

PORTUGAL Surgical Mask FFP2 / FFP3 AGPs

GERMANY Surgical Mask Surgical Mask or if

suspected/covid +ve then FFP2 / FPP3

AGPs (Dentist’s Discretion) & Covid +ve

patients (to incl. a hood)

SWITZERLAND Surgical Mask Surgical Mask if Rubber Dam

used FFP2 / FFP3 if no Rubber Dam

Covid +ve patients

SPAIN Surgical Mask FFP2 / FFP3 AGPs incl. cap & shoe cover

EU Surgical Mask FFP2 / FFP3 AGPs or Covid +ve

AUSTRALIA Surgical Mask Surgical Mask (with rubber

dam) FFP2 (if suspected or Covid

+ve)

Dentist’s Discretion dependent on procedure for –ve patients

FRANCE Surgical Mask FFP2 Yes or disposable plastic apron and cap

CANADA (BRITISH COLUMBIA) Surgical Mask FFP2 Yes


Cross Infection Protocol

Reduce Risks for staff and patients

Pandora Dental and IndepenDENTs Cross Infection Protocol This protocol aims to reduce the risks associated with aerosol generating procedures down to around 0.1% risk, and comprises 8 steps which will cumulatively affect the overall risk and reduce the impact on the provision of general dental practice.

2 Clean the mouth All patients to use an anti-microbial mouthwash which is 99.9% effective at killing coronaviruses on arrival at the dental practice.

4 Minimise droplet release in the mouth Affectionately known to dentists as ‘tooth raincoats’, rubber dams enable dentists to work on the teeth and ensure that gums and saliva are not unnecessarily exposed to the environment. Rubber dam treatment is used for every patient, wherever possible.

3 Clean the water supply It is also being recommended that hypochlorous acid (which is anti-viral and anti-bacterial) is added to the water supply used in the consulting rooms. This is an agent widely used in the food industry and it is non-toxic to people, although highly effective against pathogens.

1 Pre-treatment Screening Identify high risk to treat patients, taking history and temperature checks. We even have test kits to check IgM prior to AGP.

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Reduce Risks for staff and patients.

Cross Infection Protocol If we can reduce the overall effect on the provision of dental care using these simple steps, then the best interests of patients will be served. For example, the introduction of air purifiers can, depending on the model and room airflow, completely change the air in a room in minutes. This essential step secures the financial viability of many independent practices and ensures these vital services continue to be available in a safe and caring environment.

6 Clean the air Air purification systems have been proven to effectively remove pathogens in the air, and ensure that airborne, droplet viruses, such as Covid-19 are neutralised before they are inhaled. This pioneering technology is used widely in hospitals and clinics worldwide.

8 Reduce any infection laden aerosol spray which is released Practices have a range of high volume suction aspirator options available to deal with this problem to the extent that 99.9% of the potentially hazardous materials are safely removed.

7 Clean the consulting room and equipment All dental practices are already required to thoroughly clean the consulting room and sterilise equipment between patients and sufficient time is allowed between patients to ensure this is conducted effectively. Many practices are also installing the anti-viral clean air systems in the reception and waiting areas.

5 PPE All dental professionals working in practice to wear appropriate levels of PPE. Dr Sunny is a qualified fit tester for the mask. A survey conducted by Pandora Dental amongst 5,755 dental professionals shows only 7% experienced Covid-19 symptoms prior to the lockdown, which is much lower than the general population. This outcome can be attributed to their routine use of good cross infection control.

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“without mitigation, symptom free patients may facilitate transmission in the dental environment”

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Pre-Screening The novel coronavirus can be passed from person to person through respiratory droplets.16,17 This is significant as symptom free patients may in theory facilitate transmission in the dental environment.18 We intend to avoid a Covid-19 positive patient entering the building through pre-arrival telephone questionnaire screening and/or tele-consultations, and on patient arrival a temperature check and possibly a IgM prick test (<37.3 degrees Celsius).19,20 Antimicrobial Rinse Pre-procedural mouthwashes have historically been shown to be effective in the reduction of aerosol contamination from aerosol generating procedures.21 As the novel coronavirus is vulnerable to oxidation, a pre-clinical environment mouthwash of Hydrogen Peroxide (HP) can effectively inactivate the virus22. If the patient uses a (1.5%-3%) HP mouthwash on entering the practice, this also reduces potential spread and transmission outside of the clinical area.23 Water Supply Cleaning The SARS-Cov-2 virus has been shown to remain active and infectious in sewage and water-lines.24 Hypochlorous Acid based disinfectant has been shown to eliminate biofilms and disinfect the waterlines.25,26 Rubber Dam The airway, salivary glands and tongue are potential sites for the Covid-19 virus due to the expression of ACE2 proteins in their cell linings to which the virus binds.27 Rubber dams and specialist suction devices significantly minimise the production of saliva aerosol where high speed hand-pieces and ultrasonic scalers are used.28

Visors and Eye Protection Exhaled aerosol size depends on the characteristics of the fluid, the force and pressure at the moment of emission, environmental conditions and remain suspended in the air for varying amounts of time depending on the particle/droplet size.29 As such, protective glasses and visors are advisable to prevent direct contact of particles and droplets from suspended infectious respirator particles entering through the eyes.30

Evidence Base for Protocol


“There is no evidence that ultra-high filtration respirator masks add significant value. They are costly, uncomfortable, technique sensitive, in short supply and require scarce specialist fit testers.”

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FFP2 or FFP3 Masks? The use of standard Mask or FFP2 (N95) mask or indeed FFP3 (N99) mask and their relative effectiveness has been widely debated. Current SOP from NHSE advise the use of FFP3 (N99) masks in all Urgent Dental Care Centres. However for standard, none-aerosol generating procedures, standard 3-ply surgical masks have been shown as effective as respirator masks.31 Furthermore, For non-AGPs, there is no evidence that respirator masks add value over standard masks when both are used with recommended wider PPE measures.32 In combination with the other measures in these protocols, there is also little benefit or additional protection (0.4%) of FFP3 over FFP2.33 It makes practical sense based on this evidence to use standard 3-ply surgical Masks for non-AGP and if the other protocols are employed, fit checked FFP2 masks for AGP procedures. Gowns In all settings, when in close patient contact, scrubs with disposable apron should be used and when carrying out aerosol generating procedures, long sleeved gown.34 (reusable and washable with detergent if possible to reduce waste and continuing cost in practice). Air Purifiers (Optional) Ventilation rates, ventilation strategies, air filtration and differential pressure control can contribute to the spread of airborne infectious diseases in hospitals.35 The NHSE has recommended 30 minute intervals between patients at UDC centres based on the time taken for particle settling.36 Air purifiers that employ a combination of HEPA filtration, active carbon filtration and UVC can reduce this time dependency on their air turnover ability and the size (volume) of the room.37, 38, 39 Air purifiers measure their ability in volume cycles per hour and modern units can achieve a turnover rate of 10-20x times/hour. Wall mounted units or free standing units positioned close to the patients’ feet can optimise this outcome. 40 We advise these as optional only for practices who want to reduce surgery turnaround times and create a healthier working environment.41,42,43,44 High Volume Suction The use of high-volume evacuation HVE/suction has been shown to reduce aerosol contamination coming from the operative site by 90%.45

Cleaning Down of Surfaces and Floors Surfaces should also be clear. Disinfectants based on hypochlorous acid or chlorine dioxide solutions are active against enveloped viruses, such as 2019-nCoV and other coronaviruses.25 After each patient, cleaning down of vertical surfaces, contact surfaces and flooring with the use of hypochlorous acid or chlorine dioxide based disinfectant solutions should be carried out as per HTM0105 best practice standard14


“It is expected that the practice may move between the Phases set out in this document depending on the current Alert Risk level in the UK.”

2020_


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Novel coronavirus pandemic (COVID-19 Pandenmic) Novel coronavirus may be referred to as: • severe acute respiratory syndrome coronavirus 2, SARS-CoV-2: this is the name of the virus coronavirus disease, COVID-19: this is the name of the disease. Relevant Documents Other relevant documents to be kept in conjunction with this SOP are: PRACTICE COVID-19 risk assessment BDA Risk Assessment NHS COVID-19 guidance and standard operating procedure SCDEP guidance - Management of Acute Dental Problems during COVID-19 SCDEP guidance - drugs for the management of dental problems during COVID-19 Video consultations - process and logins document GDC - GDC guidance on remote prescribing Public Health England -PHE COVID-19 Infection Control Guidance BDA Return to work Toolkit FGDP Implications of COVID-19 for the safe management of general dental practice OCD0 C0575-dental-transition-to-recovery-sop-4-June


Dental Aerosol Procedures include: Use of high-speed handpieces for routine restorative procedures Use of Cavitron, Piezosonic or other mechanised scalers Polishing teeth High pressure 3:1 air syringe.

NB Risk of aerosols could be reduced when using a 3:1 if only the irrigation function is used, followed by low pressure air flow from the 3:1 and all performed with directed high-volume suction.

Dry guards, cotton wool or gauze can also help with drying and moisture control. Risk Assessments All staff are risk assessed on an ongoing basis to protect them and keep possible cases, household contacts, staff who should be shielded, or those at increased risk, away from work. Staff who are not furloughed are to work remotely where possible, and observe social distancing measures when in the building. Please see separate document: Covid risk assessment Staff temperature and wellness screening Screening of patients Patients are screened around 3 days before attending, and at the time of attending the practice both for risk of Covid and their risk of severe problems if they were exposed to Covid. An updated MH is completed for all patients. All patients seen at The Practice will be treated as potentially COVID-19 positive until community risk level reduces, however those who answer yes to the following questions may be at higher risk and will be treated at different times or different locations. Do you have a new or continuous dry cough? Is the temperature above 37.8? Have you been diagnosed with COVID-19? Have you or a member of your household been told to self-isolate? If the patient has COVID-19 symptoms or is self-isolating, then they will be referred to an appropriate alternative site via REGO or their GP. Please separate document: Patient Covid screening

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Vulnerable and Shielded Groups As far as possible, the management of these patient groups will be carried out remotely and invasive treatment delayed. Where face to face care is required these patients will be seen at the beginning of the day and will not come into contact with anyone other than the clinical team. The Practice will specifically identify those patients who are shielded (Individuals at the highest risk of severe illness from COVID-19 who are advised to shield themselves and stay at home for 12 weeks) and patients at increased risk. The patient’s GP and/or other dedicated health and social care professionals may need to be consulted as necessary to arrange face-to-face care in a way that aligns with the patient’s overall care needs and minimises contact risk. In the event that The Practice identifies a shielded patient or patient at increased risk as having possible COVID-19 symptoms who requires face to face care, they will be referred along the NHS pathway.


PHASE 1 The Practice will employ an urgent dental care telephone service, providing advice for their patients with urgent needs during usual contracted hours and, wherever possible, treating with: Advice Analgesia Antimicrobial means where appropriate Since the Issue 3 Preparedness Letter to 26th May 2020 all routine care at the practice ceased. Patients requiring urgent treatment have been referred using REGO to the UDC system. A video consultation may be required to see the nature of a patient’s problem - please Video consultations document. Prescribing Where remote triage is being offered the basic principles of the GDC’s guidance on remote consultation and prescribing apply (see GDC Guidance on remote consultations and prescribing in Practice SOP folder). You must make an appropriate assessment of your patient’s condition, prescribe within your competence and keep accurate records. You must have an understanding of your patient’s current health and medication, including any relevant medical history, in order to prescribe medicines safely. You must only prescribe medicines to meet the identified dental needs of your patients. You should only use remote means to prescribe medicines for dental patients if there is no other viable option and it is in their best interests. National guidance can be found at: https://www.fgdp.org.uk/news/open-letter-prescribing-antibiotics-during-covid-19-%C2%A0 Procedure: Antibiotics still need to be prescribed appropriately for the patient’s condition and should follow choice, dose and duration of antibiotic recommended in FGDP(UK) or SDCEP guidance. FGDP(UK): Antimicrobial Prescribing for General Dental Practitioners SDCEP: Drug prescribing for dentistry SDCEP: Drugs for the Management of Dental Problems During COVID-19 Pandemic

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Antibiotics should be prescribed in the following situations: If it is considered that the patient has a bacterial infection which requires antibiotics. This would include the treatment of acute apical or periodontal abscess and acute pericoronitis, necrotising ulcerative gingivitis/periodontitis. after discussion with the patient about the benefits and risks associated with the treatment options offered. with advice on what to do if symptoms continue to progress. with consideration of a follow-up call to the patient after a few days to check how their infection has responded to the antibiotics. Consider prescribing an antibiotic if there is any swelling even if it is only localised. In these situations, the prescription has a prophylactic role as ideal treatment which could be incisional drainage, extraction or opening the tooth up cannot be carried out. Antibiotics should not be prescribed in the following situations: Because of a patient request. Routinely as part of a pathway to care. Acute pulpitis should still be managed only with painkillers with regimes described above – refer to analgesic advice section. Prescribing antibiotics is inappropriate as they are of no clinical benefit in managing dental pain from this inflammatory issue. Pain on biting in the absence of swelling should be treated with pain killers only. Provision of a prescription: Amoxicillin and Metronidazole can be dispensed via the practice using the normal protocol. During the current COVID-19 pandemic it may be appropriate to use a remote medium to prescribe analgesics and antimicrobials for patients. Pharmacists can supply medication through remote prescribing provided they receive a physical prescription within 72 hours. This applies to prescription only medication. Confirm patient details and obtain consent (or follow principles of the Mental Capacity Act 2005). Explain how the remote prescription process will work and what to do if the patient has any concerns. Explain that prescription will only be provided if it is safe to do so. Explain that it is not safe to prescribe without sufficient information about the patient’s health or if remote care is unsuitable to meet their needs. Explain it may be unsafe if relevant information is not shared with other healthcare providers involved in their care. If it is unsafe to prescribe then signpost to other appropriate services; see above triage SOP. Record keeping: All records to be kept in accordance with guidelines to include justification for remote prescription. Make an entry of any prescription in the prescription log Keep a record of paper prescription sent Follow up: The patient should be advised that antibiotics will not be effective immediately but if their condition does not improve, they should seek further dental advice. Please complete an Antibiotic Audit log.


Advice on Managing Dental Pain: The delivery of advice on managing dental pain requires suitable training. Patients who are waiting for dental appointments might require basic advice on the effective management of their dental pain. Give the patient the following advice on the use of self-help measures, including appropriate analgesia to relieve pain. Avoid stimuli that precipitate or worsen the pain such as hot or cold foods or cold air. Holding cooled water or crushed ice around the tooth can help some types of dental pain. Severe pain from the mouth or teeth sometimes feels worse when lying flat; therefore, try lying propped up as this might ease the pain. Use painkillers that have successfully provided pain relief for you in the past without adverse effects. Avoid taking aspirin as a painkiller if there is bleeding. Ensure patients are reminded to follow the directions on the packet for advice on precautions in some medical conditions e.g. patients with asthma should avoid non-steroid anti-inflammatories. Advise the patient to call back if symptoms persist or worsen. PHASE 2 The principles of Phase 1 will still be implemented when the Practice is in Phase 2. If a patient cannot be managed with AAA and does not wish to be referred to a UDC or has a dental problem that cannot be managed by the UDC it may be necessary to offer a patient a Face to Face appointment at The Practice. A video consultation may be required to determine the nature of the problem in order to provide a treatment plan in advance. The treatments which can be provided at PHASE 2 are urgent and Non-AGP using Level 2 PPE; Non-AGP treatments would include*: Examinations (NB not urgent) Hand scaling with suction (NB not urgent) Non-surgical extractions - NB if this became a surgical extraction a slow speed reducing handpiece could be used for bone removal with cooling provided using saline dispensed via a syringe along with high speed suction. If this is not a suitable option, temporisation or referral would need to be considered. Removable denture stages (subject to labs being reopen and not urgent) Removal of caries using hand excavation or slow speed handpiece if necessary. Temporary fillings Recement crowns (NB not urgent unless uncontrolled pain) Orthodontic wire trimming (NB not urgent unless uncontrolled pain/ulceration) A risk assessment should be undertaken, on a case by case scenario, using clinical judgement to consider if the procedure may require an AGP or satisfies the criteria for being urgent. *NB consideration needs to be given to the current UK risk level and whether only urgent treatment should be provided. The risks of aerosol generation versus unnecessary tooth extraction if treatment can be delayed until PHASE 3 need careful consideration.

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PHASE 3 The principles of Phase 1 will still be implemented. If a patient cannot be managed with AAA and does not wish to be referred to a UDC or has a dental problem that cannot be managed by the UDC, it may be necessary to offer a patient a Face to Face appointment at The Practice. A video consultation may be required to determine the nature of the problem in order to provide a treatment plan in advance. In Phase 3 - both Non-aerosol and Aerosol generating procedures can be provided using appropriate PPE. Essential treatments may also start to be offered in this Phase, taking into account the current UK risk level and risk assessment within the practice. Please see the AGP risk matrix and mitigation spreadsheet here Fit testing completion log; PHASE 4 Non-essential Elective treatment will resume using Level 2 or 3 PPE as defined by the procedure (AGP vs non-AGP). This includes: Cosmetic procedures (facial aesthetics) Cosmetic dentistry Implant dentistry

Date Staff Tested Brand & Type of Mask


Cross Infection Control Measures The surgery should be cleaned at the start of the day before seeing any patients (see step by step guide of what to clean). Staff cleaning surgeries must be trained on the appropriate materials and equipment to use when cleaning a surgery. They must also ensure they are wearing the appropriate PPE to undertake the cleaning (gloves, fluid resistant surgical mask (Type IIR FRSM), eye protection and plastic apron). Air conditioning should not be used in the surgery at any point. Cleaning Ideally, use disposable wipes which are chlorine based at 1,000ppm av.cl, to clean and disinfect all hard surfaces, the floor, chairs, door hands and any reusable non-invasive equipment. If disposable wipes are not available use disposable cloths, paper roll, mop heads, to clean and disinfect all hard surfaces or floor or chairs or door handles or reusable non-invasive care equipment following one of the 2 options below: use either a combined detergent disinfectant solution at a dilution of 1000 parts per million (ppm) available chlorine (av.cl.) or a neutral purpose detergent followed by disinfection (1000 ppm av.cl.) You should follow manufacturer’s instructions for dilution, application and contact times for all detergents and disinfectants as these will differ across each product. Step by step cleaning guide • Clean all reusable equipment and surfaces systematically and ensure that you regularly change wipes or

rinse out the cloth in the detergent disinfectant solution throughout the process below: Ensure the whole chair is cleaned from top to base unit.

• Clean the light on the dental chair thoroughly. • Clean the foot pedals. • Clean the dental stools. • Clean the outside of any material containers used during the procedure. Where possible dispense

materials prior to the episode of care and minimise containers on surfaces. • When cleaning the surfaces, work systematically from the top or furthest away point. • Clean wall cabinets, then work surfaces, then base cabinets. • Clean the handles on units/ cupboards. • Clean the computers. • Clean the taps. • Clean the hand wash basins. • Wipe down the paper towel dispenser. • Wipe down the alcohol gel and soap dispensers. • Clean the door handle. • Clean the light switches. • Other items which are not disposable. • Clean the outside of the door handle.

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Once outside of the surgery any cloths and mop heads used must be disposed of as single use items and not re-used, even if they are designed for multiple uses. The detergent disinfectant should be emptied, and the mop bucket thoroughly cleaned paying particular attention to the outside and the underside of the bucket. Ensure enough solution is available for the full session Hand hygiene and respiratory/cough hygiene Hand hygiene, washing thoroughly with soap and water, is essential to reduce the transmission of infection. All dental staff and patients/carers should decontaminate their hands with alcohol-based hand rub when entering and leaving Hand hygiene must be performed immediately before every episode of direct patient care and after any activity or contact that potentially results in hands becoming contaminated, including the removal of PPE, equipment decontamination and waste handling. Respiratory and cough hygiene should be observed by staff and patients/carers. tissues should be available and used to cover the nose and mouth when sneezing, coughing or wiping and blowing the nose – ‘Catch it, bin it, kill it’. Hand hygiene should be performed after disposing of the tissue. Any procedures should be carried out with a single patient and only staff who are needed to undertake the procedure present in the room with the doors shut. Dental care professionals working in urgent care settings should be trained in all aspects of infection prevention and control (IPC) and fully familiar with HTM01 05 for decontamination. Training should include donning (putting on) and doffing (taking off) PPE. Cleaning staff should also be trained in IPC measures. Preparing for clinical care Follow standard infection control guidelines (see cleaning section) to set up surgery ensuring surfaces are as clear as possible. Ensure further equipment is available in clean decontamination area. Remove non-essential items from surgeries and waiting areas e.g. impression machines/books/magazines Assess equipment (kit) required for type of urgent care appointment from patient triage notes. The two members of the clinical team in surgery put on appropriate PPE. Donning of appropriate PPE should be in “clean” area. See guidance. The runner (third staff member) is to put on PPE then check COVlD-19 full PPE is correctly donned on the clinical surgery team. Complete notes in an alternative area post treatment. Staff should wear footwear that can be wiped down post treatment. The runner will remain outside of surgery door (or by hatch if available) and pass through any additional equipment that may be required during urgent care appointment. If additional equipment is required, the runner is to remove gloves, apply gel hand sanitiser and don new gloves. X-rays will be pushed under the door in a plastic bag for developing.


Patient Pathways Treatment of patients • Patient asked to complete patient assessment, medical history and other relevant forms prior to

appointment, requested to send back 3 days before appointment to allow us time to review them. • Patient should stay outside until instructed by a member of the team to enter (respecting social

distancing). • Wherever possible patients should be brought in on their own – carers should not be allowed except in

exceptional circumstances. • Only nurse and dentist in clinic area during treatment. • the patient will then be asked to sanitise their hands in reception. Ensure you remain at the safe social

distancing (2 metres) from the patient. • The patient should then be taken to the surgery and asked to be seated in the dental chair; ideally, they

should not touch any door or item other than the dental chair. • Once in the surgery the nurse and dentist should confirm the medical history of the patient directly

verbally. • Examine the patient. • Following on from examination, ensure consent to treatment is given by the patient and recorded on the

computer. • If possible, patient should rinse with mouthwash e.g. 1ml to 8ml diluted hydrogen peroxide mouthwash for

1min, or peroxyl (1.5% hydrogen peroxide) prior to treatment. • Avoid use of the spittoon and ensure disposable cardboard receiver dish or plastic cup is in place. • Provide treatment as needed. • Give verbal post op instructions to the patient. Confirm the patient has understood these as no

document/leaflet will be offered. • If required, dispense analgesics or if necessary, antimicrobials to the patient. • Escort the patient to reception to pay - Ideally this should have been paid on the phone prior to the

patient attending, if not use contactless or apple pay/ android pay. The patient should not touch any documents; this should have been sent to the patients and returned 3 days prior to appointment.

• Nurse directs the patient to the door and calls for the runner who escorts the patient through reception observing the 2 metre social distancing rules.

• Prior to leaving the building the patient must remove the gloves and place them into an appropriate clinical waste dispensary which should be located near the exit.

• Patient should leave the premises and the cleaning of the area can then commence.

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Following treatment • Patient is escorted out of the clinic. • The runner (in Level 2 PPE and remaining outside of surgery) receives dirty instruments from clinical team

in surgery, takes instruments to decontamination room and remains in PPE to follow standard decontamination process; removing gloves, gel/wash hands and applying new gloves as required.

• Clinical team in surgery should remove gloves and apron/gown/coverall and dispose in clinical waste stream, wash hands and leave surgery, shutting door behind them

• Outside surgery door, reusable visors (and goggles if worn as well) must be removed from back of head and dropped into designated box and disposable items (mask, some visors) are to be removed from back of head and disposed of in clinical waste bag (bin in corridor), gel hands - See guidance and PHE video.

• Following an AGP, the surgery should not be re-entered for at least the minimum Fallow Time (Calculated below) to allow virus to settle (see COVID-19: Guidance and standard operating procedure urgent dental care systems in the context of coronavirus V 1, 15 April 2020)

• Windows to the outside in neutral pressure rooms can be opened. • Record time of re-entry on laminated sheet on surgery door • At the appropriate time put on Level 2 PPE and re-enter surgery. Follow standard infection control

guidelines to clean surgery paying particular attention to door handles and patient contact points. See step by step cleaning guide section.

• Prepare for next patient in Level 2 PPE • Repeat after each patient • If no AGPs have been generated in the surgery, then cleaning can commence in the normal

timeframe (20 minutes). At the end of the day • Infection control procedures for cleaning and closing of the surgery should be followed with particular

vigilance to cleaning door handles, switches, chairs work surfaces or anything else that the patient may come into contact with.

• Uniforms should be cleaned daily and at the end of the day put in a plastic bag to transport home. The plastic bag should be disposed of in the household waste stream.

• It is acceptable to place uniforms in a washable pillowcase or similar provided that this is transported home in a plastic bag which is disposed in the household waste stream.

• A team debrief should take place at the end of each day to look at lessons learned and any improvements that can be made to the process will be shared and implemented. As the pathway matures the frequency of debrief may be reduced.

SunnySmiles Dental Innovations. Edited by Sunny Chagger

PPE - Personal protective equipment This section details the minimum standard of PPE to be donned. During periods of widespread community transmission of COVID-19 The Practice will use PPE to treat patients based on the type of urgent care they are providing. In the emergency phase, there is now an assumption that all patients present a risk of transmission of the virus. Waiting room/reception for meeting patients at the front door and taking temperatures all staff to wear FRSM and eye protection/visor (Level 1 PPE) Non-AGP treatment of all patients involves compliance with standard infection control procedures. This will ensure there is no contact or droplet transmission of COVID-19. Eye protection, disposable fluid-resistant surgical mask, disposable apron and gloves should be worn. (Level 2 PPE) For AGP treatment, to prevent aerosol transmission disposable, fluid-repellent surgical gown (or waterproof long-sleeved protective apron), gloves, eye protection (faceshield or visor) and an FFP3 respirator should be worn by those undertaking or assisting in the procedure. (Level 3 PPE) HSE advises that if FFP3 is not available FFP2 is permissible but requires to be fit-tested. Risk reduction of droplet contamination can be undertaken by using high-speed suction and use of rubber dam.

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Table 1: Personal protective equipment (PPE) for dental care settings

Waiting room/reception No clinical treatment

Dental surgery Non AGP treatment

Dental surgery Treatments involving AGPs

Good hand hygiene Yes Yes Yes Disposable gloves No Yes Yes Disposable plastic apron No Yes No Disposable gown* No No Yes* Fluid-resistant surgical mask Yes Yes No Filtering face piece (FFP3) respirator**

No No Yes

Eye protection*** No Yes Yes


Fallow Time Calculator

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This calculator was designed by Kris Leeson at Thorpe Dental Group. This calculator will and should be modified as new evidence is produced and research is shown to increase or decrease the effect of each factor. This should be used to assess the Fallow time associated at the end of an AGE (Aerosol Generating Exposure) by using Fallow mitigating circumstances. The mitigating factors will reduce the fallow time if safe to do so. 60 Minutes is the base level of guidance to follow if 6 air changes occur. This will be reduced if; - Airflow is increased - Air filtration occurs - Clinical aerosol can be reduced using the protocols employed in this document. e.g. rubber dam and

high volume aspiration. The amount of time an AGE procedure takes will also affect the amount of possible aerosol produced. The fallow time should be started after the end of the AGE is completed. e.g. from the time the high speed drill is put down.

Mitigating Factor

Windows Open Yes = 5 points No = 0 Points

Rubber Dam Used Yes = 5 points No = 0 Points

Air Filtration Used Yes = 2 points No = 0 Points

High Volume Aspiration Used Yes = 4 points No = 0 Points

Room Fogged with hypochlorous acid Yes = 3 points No = 0 Points

Duration of AGE 0-10 mins = 3 points

10-20 mins = 2 points

20-30 mins = 1 points

30+ mins = 0 points

Total Score =


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Reasoning for Calculation and risk mitigation; After the patient leaves the surgery, the dentist and assistant will tidy away all instruments and put them into a sealed container. Fogging could be considered, using hypochlorus acid (200ppm) with the windows remaining open. Gloves (and gowns where used) should be doffed in the surgery, although the face mask should be kept on at all times. The surgery fallow time starts from the last aerosol generation within the surgery. This should be recorded by the clinical team. All treatment rooms need to have a risk assessment to help decide the appropriate fallow time needed before the surgery can be mopped and all surfaces cleaned. We have formulated the Fallow Mitigating Circumstances (FMC) score to help. This is used to determine fallow time using a weighted scoring system, with the highest scores allocated to mitigating circumstances that are most likely to reduce the fallow time. For example, the use of rubber dam has been shown to significantly reduce the number of microorganisms present in dental aerosol by 90-98%. Opening windows will increase air flow within the room, therefore further reducing fallow time significantly. Unfortunately, there is currently very little evidence for fogging and air filtration systems so these have been scored lower. As evidence emerges this scoring system may be modified. SCORE RESULT EFFECT ON FALLOW TIME; Score of 22 = Fallow time 10 minutes. Score from 16-21 = Fallow time of 20 minutes. Score from 10-16 = Fallow time of 30 minutes. Score less than 10 = Fallow time of 60 minutes.


Back to work

Summary

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“There is no reason to delay the return to work of dental professionals any longer.”

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Main Protocols employed; With the use of; 1. Pre-visit and pre-treatment arrival screening 2. Mouthwash on arrival with (1.5% - 3% ) Hydrogen Peroxide 3. Water supply cleaning 4. Visors, gowns and masks. (Standard mask, visor, disposable apron in non-AGP and FFP2 mask (fit checked), visor and disposable/re-usable full length gown in AGP) 5. Rubber dam usage wherever possible. 6. High Volume Suction. 7. Air Purifier. (Optional) Able to turnover room air volume in under 5-10 minutes. 8. Compliant cleaning to HTM0105 best practice standards with hypochlorous acid or chlorine dioxide based disinfectant solutions Many adjustments will be required by dental professionals to adapt to the new model of practice, however this is attainable at zero cost to the exchequer by the majority of independent high street dental practices. New practices, and practices being refurbished, should consider positive airflow and upgrading air-conditioning to include HEPA filters within future considerations. If all of the measures in this protocol we advise are employed, it will be possible to maintain the safe, sound and timely operation of dentistry.


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References 1. https://digital.nhs.uk/data-and-information/publications/statistical/nhs-dental-statistics/2019-20-biannual-report 2. https://www.dentalhealth.org/oral-health-statistics 3. https://www.dailymail.co.uk/news/article-8262377/Matt-Hancock-announces-hospitals-restart-vital-services-including-cancer-care-tomorrow.html 4. https://www.telegraph.co.uk/beauty/hair/when-hairdressers-salons-re-open-uk/ 5. https://www.theguardian.com/society/2020/apr/22/how-have-the-uks-lockdown-dental-care-restrictions-impacted-you 6. https://bda.org/advice/Coronavirus/Pages/In-the-news.aspx 7. R. Shah, J. C. (2009). A national study of cross infection control: are we clean enough? British Dental Journal 8. WHO. (2020, March 27). Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. Retrieved from

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19.pdf?sfvrsn=45eb3ba9_6 14. NHSE Covid 19 Guidance and Standard operating Procedure https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/C0282-

covid-19-urgent-dentalcare-sop.pdf 15. Dehghanpour, M (2020) International PPE Guidelines. https://www.facebook.com/download/246595596655971/PPE%20guidelines%202020.pdf? 16. To, K. K.-W. et al. Consistent detection of 2019 novel coronavirus in saliva. Clin. Infect. Diseases https://doi.org/10.1093/cid/ciaa149 (2020). 17. Rodriguez-Morales, A. J., MacGregor, K., Kanagarajah, S., Patel, D. & Schlagenhauf, P. Going global - Travel and the 2019 novel coronavirus. Travel. Med.

Infect. Dis. 101578, https://doi.org/10.1016/j.tmaid.2020.101578 (2020). 18. Ruin, Li et al Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV-2)Science 01 May 2020: Vol. 368,

Issue 6490, pp. 489-493 19. IDDA COVID-19 Research Based Information and Dental Treatment Protocol

https://documentcloud.adobe.com/link/track?uri=urn%3Aaaid%3Ascds%3AUS%3A2b5d1218-b5a7-482b-b32e-80afa5de5a36 20. Peng, X et al. Transmission routes of 2019-nCoV and controls in dental practice International Journal of Oral Science (2020)12:9 21. Gupta G, Mitra D, Ashok KP, et al. Efficacy of preprocedural mouth rinsing in reducing aerosol contamination produced by ultrasonic scaler: a pilot study. J

Periodontol. 2014;85(4):562‐568. doi:10.1902/jop.2013.120616 22. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect.

2020;104(3):246‐251. doi:10.1016/j.jhin.2020.01.022 23. Xu, R., Cui, B., Duan, X. et al. Saliva: potential diagnostic value and transmission of 2019-nCoV. Int J Oral Sci 12, 11 (2020). https://doi.org/10.1038/s41368-

020-0080-z 24. Naddeo, V. Et al. 2019 novel coronavirus (SARS-CoV-2): what is its fate in urban water cycle and how can the water research community respond? Environ.

Sci.: Water Res. Technol., 2020,6, 1213-1216 25. Shajahan IF, Kandaswamy D, Lakshminarayanan L, Selvarajan R. Substantivity of hypochlorous acid-based disinfectant against biofilm formation in the

dental unit waterlines. Journal of Conservative Dentistry : JCD. 2017 Jan-Feb;20(1):2-5. DOI: 10.4103/0972-0707.209076. 26. Wang J, Shen J, Ye D, et al. Disinfection technology of hospital wastes and wastewater: Suggestions for disinfection strategy during coronavirus Disease

2019 (COVID-19) pandemic in China. Environ Pollut. 2020;262:114665. doi:10.1016/j.envpol.2020.114665 27. Samaranayake, L. P., Reid, J. & Evans, D. The efficacy of rubber dam isolation in reducing atmospheric bacterial contamination. ASDC J. Dent. Child 56, 442–

444 (1989). 28. Samaranayake, L. P. & Peiris, M. Severe acute respiratory syndrome and dentistry: a retrospective view. J. Am. Dent. Assoc. (1939) 135, 1292–1302 (2004). 29. Ferioli M, Cisternino C, Leo V, Pisani L, Palange P, Nava S. Protecting healthcare workers from SARS-CoV-2 infection: practical indications. Eur Respir Rev.

2020;29(155):200068. Published 2020 Apr 3. doi:10.1183/16000617.0068-2020 30. World Health Organization. Infection prevention and control of epidemic and pandemic-prone acute respiratory infections in health care Geneva, WHO,

2014. 31. Greenhalgh, T et al. What is the efficacy of standard face masks compared to respirator masks in preventing COVID-type respiratory illnesses in primary

care staff? https://www.cebm.net/wp-content/uploads/2020/03/COVID-CAT-PPE-MASKS-9-REVISED-002.pdf 32. Long Y, Hu T, Liu L, et al. Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis [published online

ahead of print, 2020 Mar 13]. J Evid Based Med. 2020;10.1111/jebm.12381. doi:10.1111/jebm.12381 33. Howe MS. How much extra protection does an FFP3 mask offer in the dental surgery? post 30.4.2020. Accessed 3 May 2020. 34. BME, COVID-19: PPE for doctors. https://www.bma.org.uk/advice-and-support/covid-19/ppe/covid-19-ppe-for-doctors 35. Shajahan A, Culp CH, Williamson B. Effects of indoor environmental parameters related to building heating, ventilation, and air conditioning systems on

patients' medical outcomes: A review of scientific research on hospital buildings. Indoor Air. 2019;29(2):161‐176. doi:10.1111/ina.12531 36. Hinds WC., 1982, “Aerosol technology: Properties, behaviour, and measurement of airborne particles”. New York: Wiley; 1982:6-8., 37. Chen C et al, 2010, “The effectiveness of an air cleaner in controlling droplet/aerosol particle dispersion emitted from a patient's mouth in the indoor

environment of dental clinics”. J R Soc Interface. 2010 Jul 6; 7(48): 1105–1118 38. Hallier C, et al. 2010, “A pilot study of bioaerosol reduction using an air cleaning system during dental procedures”. Brit Dent J. 2010 Oct 23;209(8):E14 39. Darnell, M. Et al. Inactivation of the coronavirus that induces severe acute respiratory syndrome, SARS-CoV. Elselvier, 3 August 2004 40. Morowska L et al Airborne transmission of SARS-CoV-2: The world should face the reality Environment International Volume 139, June 2020, 105730

https://doi.org/10.1016/j.envint.2020.105730 41. Yadav, N. Et al Role of High-Efficiency Particulate Arrestor Filters in Control of Airborne Infections in Dental Clinics.Journal of Research in Dental

Sciences 2015 42. Chen, C et al. The Effectiveness of an Air Cleaner in Controlling Droplet/Aerosol Particle Dispersion Emitted from a Patient’s Mouth in the Indoor

Environment of Dental Clinics. Department of Periodontology, Peking University, Beijing 2009 43. James, R. Et al. Dental Aerosols: A Silent Hazard in Dentistry International Journal of Science and Research 2016 44. Vanderbroucke-Grauls CM, Teeuw KB, Ballemans K, Lavooij C, Cornelisse PB, Verhoef J. Bacterial and viral removal efficiency, heat and moisture exchange

properties of four filtration devices. J Hosp Infect. 1995;29(1):45‐56. doi:10.1016/0195-6701(95)90292-9 45. Harrel SK, 2004, “Aerosols and splatter in dentistry: a brief review of the literature and infection control implications” Apr;135(4):429-37.


Appendices

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Hand-washing


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Non-AGP: Donning of personal protective equipment (PPE) For non AGPs


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Non-AGP: Removal of personal protective equipment (PPE) Non-AGP


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AGPs: Donning of personal protective equipment (PPE) For AGPs


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AGPs: Doffing of personal protective equipment (PPE) For AGPs

STANDARD OPERATING PROCEDURES to allow dental practices to reopen. JUNE 2020 Protocol to allow dental practices to reopen. May 2020

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Recommended PPE for primary, outpatient and community care by setting, NHS and independent sector

STANDARD OPERATING PROCEDURES to allow dental practices to reopen. JUNE 2020 Protocol to allow dental practices to reopen. May 2020

Let’s get Dentistry Back to Work

Contact & Authors :

Issued on behalf of The IndepenDent Practice Owners UK

Co-authored by Dr Adam Nulty, Dr Vicki Holdon & Dr Kris Leeson

With Special Thanks to other contributors;

Pandora Dental Group, Dr Mark Cronshaw, Dr Tasleem Ahmed, Dr Nicola

Gore, Dr Petros Mapanda, Dr Michelle Wyngaard, Dr Robin Horton, Dr Ross

Campbell, Dr Cohan Rajan, Dr Jeremy Bliss, Dr Charlie Ferber, Dr Bashar al

Naher, Dr James Shorrock, Dr Ash Parmar, Dr Nadia Raitchev, Dr Ivo

Raitchev, Dr Lynda Raybould, Dr Jim Hurson, Dr Ketan Kothary, Dr Elisa

Facco, Dr Raj Singh, Dr Nicola Ritchie, Dr Raj Wadwhani, Dr Connor

Gallagher, Dr Gareth McAleer, Dr Adam Glassford, Dr Rhone Eskander, Dr

Mario Correia, Dr Mahesh de Silva, Dr Moona Malik, Dr Wasim Fazel, Dr Ashish

Deved, Dr Mark Becker, Dr Neesha Patel, Dr Paula Brennan, Dr Saleh Aria, Dr

Philip McDermott, Dr Arun Darbar, Dr Leo Duran, Dr Ashruf Peer, Dr Andrew

Parashchak, Dr Gareth McAleer, Dr Patricia Szymczak, Dr Pejman Khaki, Dr

Ajay Murgai, Dr Alfonso Rao, Dr Wayne Williams, Dr Claudio Peru, Dr Theo

Visser, Dr Lindsey Whitfield, Mr Gary Miller, Emily Cameron and Tracy Posner.

During the Covid-19 Crisis

Issued on behalf of the IndepenDent Practice Owners UK

Co-written by Adam Nulty & Vicki Holden

D E N T A L P R A C T I C E S T A N D A R D O P E R A T I N G P R O C E D U R E S