Cambridge practice tells of changes for a visit to the dentist

The dental community has had to work – and invest – harder than many businesses to organise an emergency service during the pandemic: with just four dental centres remaining open in the region – including Antwerp Dental Practice in Cambridge – the appointments system and all medical procedures have been radically and rapidly overhauled.

Dr Raj Wadhwani, clinical director of Antwerp Dental Group, whose main office is Antwerp House Dental Practice at 36 Brookfields, operates one of the designated Urgent Dental Care Centres (UDCCs) around Cambridgeshire.

Says Raj: “I settled in Cambridge in 1993 and realised the need for NHS dental services locally. I set up Antwerp House originally as an NHS clinic in 1999, and since have diversified the clinic to a combination of NHS and private services, including specialist services.

“Antwerp House was originally a guest house and has been redeveloped over the years to become a state-of-the-art dental practice. Our dental activities have expanded in several suburban towns close to Cambridge where we operate a similar patient care ethos, and systems, to promote quality.

“We’ve essentially developed a practice cluster which is locally based and operates as a hub-and-spoke model, with a team of dental specialists based at Antwerp House and a cluster of practices within a 15-20 mile radius which work collaboratively with Antwerp House. Our overall objective was to create a centre of excellence at Antwerp House and to promote educational values across our practice cluster.

“The Covid-19 pandemic has thrown a massive spanner into the works and we cannot operate as we had done. We cannot perform face-to-face consultations with patients so, in accordance with standard operating procedures issued by NHS England and Improvement, we have set up a telephonic triage service with view to referring real dental emergencies to our UDCC.

“Where a telephonic consultation does not provide sufficient detail, our patients are sending photos of their mouth or we are engaging a dental teleconference. Where we can provide the so-called triple-A approach – advice, analgesia and antimicrobials, which is antibiotics, we are seeking to stabilise patient’s conditions.”

In late March, the government established Urgent Dental Care Centres (UDCC), a voluntary scheme to provide emergency services for patients in severe dental pain.

“In the first round there were 92 centres across England,” says Greg, director of operations at Antwerp Dental Group. “We were one of the ones in that first wave, and the number of centres has now been expanded to 300-plus. The only barrier to everyone setting up in this way is access to PPE. On April 1, when we were one of the first, we had our PPE delivered via the NHS.”

“It was through the NHS’ National Supply Disruption Response team,” adds Raj, “which involved the armed forces being used in the NHS supply distribution chain. Antwerp House is the only practice within Antwerp Dental Group operating as a designated UDCC, although we have offered NHS England the opportunity to use other practices. This has been kindly acknowledged – but there’s a problem with supply of and access to PPE. Supply has to be concentrated on the NHS effort at the front line of acute medical care, but as more PPE becomes available UDCCs will expand, though it’s currently limited.”

The volume of PPE involved in a trip to the dentist since April 2020 has increased phenomenally. The amount of contact the patient has with door handles, surfaces and everything else in a surgery has to be reduced to minimise the risk of viral transmission by contact – so-called “fomite transmission”.

“It’s controlled entry,” says Raj. “The patient sanitises their hands on entry, proceeds through the guided entry process. The nurses open the doors inside. It’s full masks and gowns for the dentist and nurses – that’s hair nets, visors, double gloves and full body gowns. There’s eye protection available and, where available, nets can be worn over shoes. Dentists and nurses gown up for each patient.”

Why would you wear nets over your shoes, I ask?

“Vital matter can be re-suspended from the floor when there’s footfall on it,” says Raj. “Shoe nets are not common due to lack of PPE, so practices are asked to risk assess their premises and procedures and promote additional sensible procedures on top of our usual standard infection control procedures, which might include more frequent mopping of floors with bleach.

“We take six patients a day maximum. Where an aerosol-generating procedure is conducted, we allow a one-hour gap between patients. The gap between patients creates a buffer zone which allows aerosol to settle.”

But what about the patient, what PPE do they have?

“Some will wear a mask on entry if they want, but there’s no requirement and they take it off in the dental chair for obvious reasons. They sanitise their hands before entering the treatment room and have a pre-procedural mouth rinse – it’s an oxidising agent that’s been found to destroy the virus, so we do that routinely.

“The chief dental officer for England, Sara Hurley, has issued standard dental operating procedures – we can only see one patient per hour, there are Covid risk assessments in place including questions such as is there anyone in the family with symptoms, a persistent cough or a temperature or allied symptoms of Covid-19. The triage process involves two levels of triage with two different dentists – one being the patient’s own dentist – and they take the Covid risk assessment in that process before the second triager authorises a referral to the UDCC. There are designated Covid-positive and Covid-negative dental sites in the UK. We’re a designated-negative site.”

“If the first dentist says you need treatment, the second dentist has to agree for it to happen,” adds Greg. “This safeguards the UDC from unnecessary referrals.”

These processes have been very rapidly implemented.

“NHS England sought expressions of interest to be an UDCC site and we put our expression of interest in early,” notes Raj. “The system kicks in when the person with dental issues calls in to their local dentist who completes a patient care pro forma, and sends this to a Covid-19 East of England inbox. These messages are picked up by a number of level II triagers – dentists who operate practices across our region. Antwerp Dental UDCC is contracted by the second triager to carry out the service at the front line.”

The elaborate process involved for each patient to have their dental work done means only 30 patients can be seen a week, and the cost of this model is unsustainable financially – but Raj has chosen not to furlough all of his staff to support this process.

“It’s not sustainable but we decided it’s something we wanted to do,” says Greg of the service. “We wanted to do something for our patients but it’s primarily because we’re a mile from Addenbrooke’s Hospital, not an hour goes by we don’t see an ambulance going past.”

The very good news is that the company was able to obtain a CBILS (Coronavirus Business Interruption Loan Scheme) loan from its bank, Lloyds, without any fuss.

“We knew,” says Raj, “from the outset, judging from the early Covid-19 experience in China, that we would close for several weeks. Our operational costs are significant, more than £500,000 a month, so we needed to model a very careful cashflow forecast. Myself, Greg and our finance team identified how much money we’d need from that model, but in fact our bank manager called us in late March, and said ‘we know you’ll need help’, so we applied for a CBILS loan on April 4, and the loan was approved on April 8.”

The £550,000 loan should take the company through “to early July”.

Greg said: “We monitor how we spend it very closely, we’re trying to make it last as long as possible with a six-year repayment on a favourable interest rate and a repayment holiday. We have a very proactive Lloyds healthcare director, so when we started talking about loans he knew exactly how our business operated and got it approved without any questions.”

It is all rather impressive – and very reassuring for those seeking emergency dental treatment.