This episode aims to navigate the Dentist around the complicated world of Respiratory Protective Equipment (RPE). I literally start from the basics and we build up – hope this helps!
- What is a Fit test vs Fit check
- Who should be paying for the FFP masks?! Associates?!
- Oops I failed my fit test – what now?
- Should we just drop FFP2/FFP3 and just use re-usable RPE that is way more cost effective?
- UDCs are reportedly keeping the same FFP3 mask on for several patients (1 per session) with a surgical mask on top – if they are getting away with it, can we do it in practice to save money?
- Does FFP2 NEED to be fit tested? Can you get away without one if you compensate with a face shield?
- What’s the difference between FFP2 and FFP3?
- What does a FFP even mean?
- Should you be stocking up now?
- Watch out for the fakes!
- Will there be a phased return or ‘chaotic return’?
- If I am antibody positive, do I need to bother with all this?
- DO we need more fit testers? How to get involved?
- How are we going to meet the healthcare demand of fit testing?
- When do you think I’ll get to place composites again?!
Click below for full episode transcript:Opening Snippet: Hi, guys, welcome to another episode of Protrusive Dental podcast...
This one’s all about respiratory protective equipment. It’s a massive, massive topic at the moment. And I just want to help out by covering a little bit mostly because I felt as though I knew nothing. And I had some people reach out to me, what do we do about our beards? Do we get FFP2s, fit test it, this will make a good topic for your podcast. So I reached out some guys, it culminated in this episode, which is going to cover all the very basics of the more sort of political ethical questions around RPE in dentistry, for whatever it is that we’ll be getting back to work. I know the UDCs are working under some conditions whereby they have access to some forms of RPE. So discussing all that, I have to give a disclaimer that one of the reasons I made this episode was because I am concerned as a Sikh man, with a turban and a beard, but how I’m going to go back to work and certainly for those in my community, how are we going to get back to work and I want voice or my community to be heard. So that’s one of the reasons but that makes up around about 0.2% of this podcast. This podcast episode is applicable to everyone. But I do want to reach out to my community and sort of offer them something. And basically, there’s not much in it in terms of how I can help people with beards, Muslims, Jews, Sikhs, those of us who have facial hair, essentially, we are at the mercy of the higher powers, the WHO, Public Health England, the CDO, NHS England. So all these bodies are advising us. And actually, they are all blind. And what I mean by that is that there is just not enough evidence yet. So I think the method that everyone is now adopting is a better safe than sorry, hence why at the moment, the guidance suggests that you should be using a filtering SPS for any AGP related procedures. So that’s where that guidance comes from. It may be that just a surgical mask and a visor is just as good. But the thing is, we don’t know yet. I think the due to political reasons, and due to safety first and being better to be safe than sorry, that’s the reason that we’re going a bit extreme into some of the guidance recommendations in terms of worker needs to wear these FFP2 or FFP3 masks. So I think that’s where that comes from. The only thing I can say is that I was surprised to learn a little bit that all this RPE that we wear is actually mostly to do with protecting us, not so much the patient. Yes, the patient’s important as a byproduct, the patient should be protected. But we’ll also think about how to protect us as interesting that, for example, if I was to wear an FFP2 mask with my beard, technically, I wouldn’t get certified to wear it because one of the guidelines is that you should be clean shaven. So we know that the seal actually degrades and you can’t be certain that every time you do a fit check that you’ve got a perfect seal. So for that reason, we think that yes, the dentist is not protected, but actually the patient, maybe we just don’t know, because the dentist can still exhale. And we don’t know how much of that exhalation can affect the patient. We don’t know how much of the viral load is carried in exhalation yet. We just don’t know the answer. And of course, the majority of the masks that are available, RPE that is available in UDCs due to political reasons and supply reasons actually have an exhalation valve. So the air, the exhalation, air is actually coming out anyway. So that to me, that seems no different to me, wearing FFP3 and knowing that I don’t have 100% seal. So I don’t really see that being any different. So there are lots of unanswered questions for people with beards and stuff. So that’s the best I can offer. We really need a solution that not going to depend on hoods, because they’re so cumbersome. Anyway, we cover all that and much, much, much more. Like I said, the beard thing is only a small part of this podcast. I really hope this helps everyone to understand about fit testing, fit checking which mask do we need? Why? Is it a legal requirement to wear these masks? Who is protected? Who’s not? How much these costs? Is it better to just buy a reusable one than a disposable one? So all these things we covered, I generally hope that you find this useful. Thanks so much for tuning in. [Tarik]
That’s number one. Number two, we don’t know there’s a lack of evidence or there’s no evidence on aerosols and risk of transmission, so we don’t know. So there may be the fact that we get more evidence, there is, maybe we will get different respirators that would come onto the market. And maybe we don’t need them.
Welcome to the protrusive Dental podcast, the forward thinking podcast for dental professionals. Join us as we discuss hot topics and dentistry, clinical tips, continuing education and adding value to your life and career with your host, Jaz Gulati.
Right and Gentlemen, welcome to Protrusive Dental podcast. It’s great to have have you on. I want to make this the most impactful episode about PPE and RPE in the current climate. Let’s start with some introductions. Tarik, thanks for reaching out to me. Please tell us about yourself and what makes you qualified if I say to talk about PPE and RPE? [Tarik]
So my name is Tarik Shembesh. I’m a dentist, oral surgeon. And for the last eight weeks, I’ve been redeployed as a fit tester. I’ve been testing qualitatively and quantitatively, have coordinated a large team of multidisciplinary dental professionals in fit testing, supervising them, educating them to colleagues, I’ve been conducting respiratory protection education, as well as raising awareness about respirators and fit testing. [Jaz]
Perfect. How about you, Kareem? [Kareem]
Hi, Jaz. Thank you very much for having me. On the show, my name is Karim dadly. I’m a consultant and the statistics at a London COVID teaching hospital where we have a large population of COVID patients that have been through our doors in the last two months or so. What makes me qualified is that I have not seen a patient that does not have COVID in the last two months, I only look after COVID patients at the moment. So therefore, I wear RPE and PPE every day when I’m at work. I’m also the research lead for our Directorate. And so I’ve done a little bit of research on amongst other things, but on COVID and RPE and PPE, I’m by no means an expert. But I would say that I’m equipped to talk about the RPE and PPE from a day to day experience basis as well. [Jaz]
That is fantastic. And I think we’re going to learn a lot from your experiences because what we’re about to face is dentist going to the work and Doc Sami, please tell us about yourself. [Sami]
So I’m an oral surgeon I’m Sami Darwish an oral surgeon and a periodontist. And I am not on the front line, like these two chaps are. But together we have created an organization where we have been going around fit testing dentists in preparation for them providing clinical services. So far, it’s just been the UDCs. But we’re moving into helping the other dental practices open up and ready for service. That like Kareem is the lead researcher in his unit. And I’ve had a couple of publications out there in the dental literature. So I guess together the three of us and the huge team that we’ve managed to put together now of over 40 fit testers, we now created a network of fit testers that’s providing the service according to the need, and put ourselves in a good system going in getting people ready to go back to dentistry. [Jaz]
Brilliant, thank you to all three of you for your roles in what you’re doing. And during this time. Whether you’re on the front line, or you’re like do something behind the scenes, it’s great that you’re doing this work. Do you know how many people or how many healthcare professionals have been fit tested by yourselves? Do you have a like a rough number? [Sami]
Last count was a few days ago, which was 500 and something [Kareem]
Yeah, top 560 570. [Jaz]
Brilliant. And what are the main things that you’ve learned from doing it? What is it? Well, I want to know is what’s the pass rate of fit testing? So you’ve done 500 people, but their first time when you test them and then maybe what percentage pass and then maybe then you have to try another brand. Give us a flavor of what’s going on behind the scenes for someone some of the dentists who have no idea who haven’t been to the centers to be fit tested. What actually goes on? [Tarik]
Let me start by saying what’s a fit test? Fit Test is just a confirmation or a an assessment of the performance of that respirator on somebody’s face essentially, is it compatible with the person his facial features and in particularly the lower mid face. Now we are a dentist where our team is multidisciplinary dental professionals. We measure the face, we use 3d scanning as well. And with that techniques, we’ve managed to find out with our experience and as we go along, what is the most suitable Or what’s the most likely to be the most suitable RPE, but also constrained with what’s available. So to answer your question, what’s the pass rate? It depends on what variety of RPE we have, and what the demographic that we’re faced with. So in a session where it’s mainly petite women, then probably the pass rate will be low, as low as 30%, where we have mainly a male demographic, and we have a variety of respirators, then we would have as high as 80 to 100%. So changes from session to session. Overall, I’d probably say around 70% mark [Jaz]
70% is a pass rate. Yeah. [Sami]
Yes. Over all 70% pass. But Tarik, do you want to just elaborate slightly on why the petite female group are more likely to not pass [Jaz]
Because that petite female group is a large percentage of our current, you know, healthcare professionals, my wife included who failed the test. [Tarik]
So there are many reasons, Jaz, first of all, respirators are traditionally the respirators essentially that we’re using our industrial products. And we know in industry, it’s mainly men, larger sizes, that’s number one. Number two, we are in a pandemic, where there is shortage of PPEs, shortage of variety of RPEs, ideally, a fit tester should arrive somewhere with a variety of RPEs different sizes, different shapes, and then they see the most suitable, the same as somebody where if you were buying a pair of jeans, you would go to somewhere, they will have all the different sizes, they would have all the different styles. And based on your shape, your size, what you were wanting to do with it, you may get with a stretchy one, you may go with a different color one, and you end up with a best pair of pants that you want to do for that job that you’re doing. [Jaz]
The supply is limited, the variety is probably limited during this time. Kareem, you raise your hand, please. What are your experience has been? [Kareem]
Yeah, effectively. Really, the problem with RPEs as Tarik highlighted, they’re all designed for white men. And so if you’re not a white man, your chances of passing a fit test are diminished. The studies have shown that up to across all backgrounds around a fifth of of people do not pass the Fit Test. Now, of course, the demographics in the UK. And the demographics in dental practices may be slightly different to the general population demographics, of course, and so the chances of you not successfully passing a fit test might be affected by that as well. [Jaz]
So then, logically, the next thing want to check then is this significant percentage of the population who may be due to the lack of variety available at the moment, and their facial features will not pass these fit tests, what are we gonna do? Let’s say the government said, or the powers that be that say that we can go back to work on the Fourth of July just made up a random date. What are we going to do? [Sami]
We need to I mean, that’s the whole point of fit testing. I mean, what we aim to do, as fit testers is seek a answer to what the effect of the mask that the dentist is holding. Is that functional or not? But what we aim to do is also test them on a variety. So if they fail on one mask, then there’ll be other masks to test them on. [Jaz] Hopefully. [Sami] Oh, hopefully, yes, hopefully. I mean, as the chaps just said, is that traditionally this mask has been designed for the firemen and the construction worker. And one may hope that the industry might change to make masks for the medical and the dental profession. And I’d expect exactly that to happen. But notwithstanding that there will still be masks that dentists will fit. So if the first one that they’re holding ends up being the one that doesn’t fit them, then we can access alternatives for them, test them on it, and one would hope and the second, third or fourth attempts of a different mask, we find one that does fit them. Once we do, then that’s the one that we tell them, this is the one that fits you. So that’s the one that they need to go and look for and buy. [Tarik]
The reason why there is fit testing now is because mainly we are dealing with what’s available to us. And we are in a middle of a peak of a pandemic. Yeah. So we don’t know what will be normal routine dentistry, and we may not need respiratory protection. That’s the first thing. Yeah. And I hope that we don’t, because it’s not the most practical. And to be honest, I used to love how I used to practice dentistry. And at the moment, I don’t love it as much. But at certain aspects of it, falling in love the slowness of it, the flow of it. But I’m not a big fan of having something bulky in front of my face and for my patient. Last week, a 10 year old child having to see me with that respirator on. That’s number one. Number two, we don’t know there’s a lack of evidence or there’s no evidence on aerosols and risk of transmission, so we don’t know. So there may be the fact that we will get more evidence there is maybe we will get different respirators that will come onto the market. And maybe we don’t need them. Also, don’t forget that we were taught in respirator terms on respiratory protection, there are two classes of respirators, there are close fitting respirators, and there are loose fitting respirators. Loose fitting respirators don’t need to be fit tested. And they are adequate and suitable for any shape, any size. Again, they’re not the most, they’re designed mainly in for industrial applications. But [Jaz] Can you name some examples? [Tarik] So there is the one that has been developed in Southampton University, I believe. And it’s Persil, which is an alternate system which can be perhaps adapted and perhaps developed further. There’s also a MaxAir, which I believe Kareem has some experience with. And perhaps Kareem can tell us more about it. [Kareem]
Of course I experienced with the MaxAir. And these are effectively powered air purifying respirators. So these the PAPR is Powered Air Purifying Respirators are effectively a hood that you will have seen people wearing before. And what they have is they’ve got a pump. And that pump effectively produces positive pressure within your compartment where you’re breathing within your head. And then that positive pressure effectively forces air out course the pump, and the fan has a filter on it. Okay, so it’s a highly efficient filter usually, and you don’t have any tight fitting mask on your face. But you’re effectively within this hood. There’s various types of powered air purifying respirators, of course. And Tarik has named a couple and they’ve got different designs, some of them have the pump that sits on top of your head, some of them have a tube and the pump sits on your head disconnected, but the principle remains the same as you’re in a positive pressure chamber. Your head is in a positive pressure chamber that has a filter to prevent viral particles entering [Sami]
What’s it like walking around with it. [Kareem]
Which one? The Oh the PAPRs? [Sami] Yeah. [Kareem] So it really depends on the PAPR, right? Like some of them are really, really super industrial, super bulky, and have space inside. Of course, what you notice is that sound is a little bit more muffled. Communication is more difficult. You can’t get close to things because you know you’ve got this distance between you and and the respirator itself so it can be challenging. To be honest with you, there’s the ones that have, that sit on top of the head. They have advantages because they use a disposable visor. Okay, so the hood itself is disposable, but the pump is not and the pumps, it’s inside that disposable hood, and you do have a buzz that’s sat on top of your head a little bit of a hum that’s constantly there, but you get used to it after a while. But listen, end of the day, it’s nothing is as comfortable as having nothing on your face or your head. Right? You ideally don’t want to wear a mask, you ideally don’t want to wear a hood, but you’ve got to protect yourselves and and if you can’t fit a mask, then you’ve got a try hood. [Jaz]
Well, I’m glad you answer that. So yeah, if the mask is no good and tried a few then maybe the next step will be a hood. But until I guess we know what the standard operating procedures will be that we really don’t know which direction there’s going to head in. So I We respect that none of us know the answer to that. But one thing we do know is that Irish guidance was released and they’re advocating FFP2. Now this FFP2 need to be fit tested. And I also want to know, what if the, the ability to for the fit testers and I believe there’s a limited number of fit testing kits as well to these many bottlenecks in the system that may prevent everyone getting access to fit testing, and then maybe we’ll further delay who can get to work. So please, can you talk about that? [Tarik]
So if I can take your first question first of all, when we do our teaching, we, the first principle is a surgical mask is a surgical mask, it’s a barrier protection, that offers some filtration, which is not standardized, whereas a respirator is a filtering device that also offers some protection, but most of the time, that’s not fluid resistant. So FFP2 is a FFP stands for a filtering facepiece. Yep, with P1 capability, P2 capability, P3 capability. So essentially, an FFP2 is a filtering device. Yeah. And any filtering device, any respirator requires a seal for it to optimally perform. Yeah, because it’s a respirator, you want it to filter, you don’t want air to escape in from the sides, you wanted to have a seal. The only standardized way and recognized way to test that seal on a person’s face is through a fit test, which couldn’t be qualitative or quantitative. So if a an employer or a wearer wants to know the performance of that filtering facepiece, regardless of its being FFP1, FFP2, FFP3, they do a fit test, if they pass a fit test, that tells them that there is a fit factor of at least 100, which means that if there is 100 aerosols outside, there is less, there’s one aerosol will get one particle, various 100 particles outside one particle will get in. And that’s a, what we call a fixed factor of 100. [Jaz]
Can I just saidyou understand that point that even though you get a positive fit test, and you’re happy with a brand, and then the Fit Test to say goodbye, and everyone continues. If you just on one day, changes position slightly, you don’t put it on properly, then that may again be ineffective, right? [Tarik]
Part of the program. And part of the products that we do is people will say to us, oh, come and fit test us, we can kind of do the fit testing. But that’s not half of it, we need to train you on how to wear it and how to don it and how to doff it, how to put it on safely, and how to take it off safely. And how to take care of it with the reusable ones, how to inspect it, how to clean it. So you’re quite right, if the wearer hasn’t had adequate training, in how to use it, it could be ineffective. [Kareem]
I think it was one way that I like to compare it to is driving, right? So getting your fit test done. And, you know, passing the Fit Test for a certain mask is like getting a license for that vehicle. Okay? For that type of vehicle, it means that you can drive that car, so you get an automatic license, it means you can drive an automatic car, great. But having that license doesn’t mean that you know how to drive and it doesn’t mean that you’re going to be driving safety, you still have to adhere to the principles of safe driving. So if you get that license, that’s the same as passing your Fit Test. But if you drive with your window, with the door open, with no seat belt above the speed limit, then the driving license is effectively meaningless. It’s a package right? It’s about training and implementing safe practice, which includes part of that safe practice includes getting that license or passing that fit test. [Sami]
So Kareem I think that’s a really important message that you just said, because I’m getting the impression that people just want to be fitted and say, Oh, can you come over? Measure me up? Tell me which mask is aware so that I can get on, I can book a patient in next week. And it’s actually so not like that. What’s just as important as you selecting a mask to fit your face is actually you knowing how to use it. And so, I would, I just, I want to express to colleagues to take with severe caution. Any form of Fit testing that they may be looking for, which is just a better come and measure me up and certainly out. It’s just so not like that. [Jaz]
So thanks so much, gentlemen, my question I have for you now is, until the standard operating procedures are released for England and certainly UK, obviously Irish guidelines have been released. Your advices, for example, I’m a private dentist, should I be rushing out to get fit tested? Is there any reason I should be now? Or should I get try and get ahead of the curve? What’s your current advice to a dentist in my situation? [Sami]
Can I answer that from the ethics point of view? So although we are being providing fit testing and we are responsive to people’s requests, I think there is a an ethical angle to this, in that PPE is limited as you’re seeing in the media. And I would think it’s particularly, a little bit particularly unethical if dentists who are currently shut down in effect by the CDO are getting fit tested and stocking up their respirators to sit in a cupboard inside a closed dental practice. But saying that, I’m also aware that we need to get ourselves prepared. So I think when it looks eminence that we’re going to be opening up, then gradually, we as a professional, as a team, should be preparing ourselves. Let’s start with our take, to take away from the frontline who are, of course, a very valid point anyone in need. [Tarik]
On a technical point, most PPE that I see or RPE that I see available on the marketplace. Or when we go to UDC, whereas to so at the moment, we have official supply that has gone been procured through NHS England, and Public Health England to the end of the session, once we’ve empowered them with all the information, there is some supply that came not from that official supply and they don’t perform in the same way. So most of what’s available now in the marketplace, especially KN95. Other nasty emarkets, there is fake respirators, there are earloop designs, the ones that are not basically used on the front line, they don’t perform as well. So fit testing should be done on a RPE that you know that is likely to fit you. It’s on an RPE that it’s likely that you will get more of it in the future. And an RPE that you’re not taking away from an operational site because there is shortage of supply, we’re likely to be in phase returned to dentistry, I don’t think it’s going to be chaotic returned to dentistry. There are so many other ways that we know that we can prepare ourselves. I wouldn’t though ignore the topic and not engaged, I would engage with a testing team, I would engage and raise awareness on respiratory protection as a whole. Because knowledge is you know, it’s never, you can never waste getting more knowledge. But buying unofficial PPE from unofficial sources, and buying it in bulk without engaging a fit testing team, I think is definitely the wrong approach. Having a sample of some RPE that are likely to be available later on aan engaging a fit testing team that will empower you with knowledge and how to do it properly. I think is the right way forward, personally. And that might change next week, if the guidance change if the supply chain changes, if what we’re being asked to do s different from our experience, returning to work should be a coordinated, professional step. Shouldn’t be done on an individual basis. There are communities of practice, you have a network of colleagues around you and doing it as part of a coordinated approach with your local professional network, I think is the right way forward. No matter what what that step is. And no matter what the preparation is. I think if this time taught us anything, we need to come closer as a profession. We need to come closer as different professions and different workforce and help each other out in a time of need. But Also we should carry it on and use expertise in different sectors and help each other out. [Jaz]
Brilliant. So, gents, next question I have is sent in by one of the listeners who I encouraged to, you know, send any questions we have for the group today. And when I borrow your knowledge here, is with the antibody test being more widely available now. And certainly I’ve been looking online, I’m very keen to get one ASAP. So that hopefully I won’t have to wear a hood , it’s my thinking. Now, can I go back like how it used to be? Can I go commando if I’m antibody positive? [Kareem]
Yeah, I mean, firstly, I don’t like the idea of going commando, ever anyways. But there’s two points here, I think firstly, is you’ve got to make sure that the kit that you’re using to test yourself is validated, right? Because there’s lots of kits that are out there that you can buy. But one of the reasons why it’s taken so long for the government to approve something is because the validation processes are quite rigorous. And if you’re using something that’s not validated, then you may get a result which either will be also reassuring, or falsely concerning that may not be accurate. So that’s the first thing. So the second point is, we’re still learning so much about this disease right now. Okay? Sohaving antibodies to SARS COVID2, doesn’t, firstly, you can have asymptomatic zero converters. Okay? So there’s a large population of people that some studies have now suggested up to 44% of healthcare workers are asymptomatic zero converters, which means that you’ve got the antibodies without having declared any symptoms. But having the antibody does not necessarily mean you will have lifelong immunity. We do not know how long the antibodies will last, we do not know how the virus will adapt and change. So at the moment, I don’t think that it’s a wise idea for us to say, you know, I’m all good, I’ve had it, I’m immune, it’s done. We still don’t know. And I work very, very closely with our virology and infectious diseases department. And we’ve done several studies, and we’re working on lots of studies on at the moment, and certainly, directly from them, they categorically say, you cannot assume that if you’ve got the antibodies that you’re going to be in the clear, I’ll give you an example, we intubate patients with COVID, all the time, and about a 10th of clinicians who are involved in intubation patients have gotten COVID. Okay? I have several colleagues who have had COVID, swab confirmed COVID. And despite that, when they returned to work, there were in full RPE and PPE. So I think that it would be playing with fire if you think that having the antibodies on a test means that you’re immune forever, because we really don’t know enough yet. [Jaz]
Okay, fine. I think that’s an answer categorically that No, you shouldn’t go commando. So if your antibody positive until the research is out there to suggest otherwise that we should still go with whatever the SOPs will be once they come out. That’s a fair summary. [Kareem]
Yeah. And we need to be we need to be guided by the evidence. And the evidence is still it’s way too early for us to draw any definitive conclusions on anything and to take any risks. So until we have definitive evidence, let’s play safe. And let’s do the right thing. [Jaz]
As talking as someone with a beard, I’m sure obviously, you know, the issues well. You’ve been subjected to many people you’ve tested, or you’ve probably declined to test, if someone’s got a beard, you’re probably not going to test them, you can have that conversation about shaving. Now putting religion even inside because I know I’m a Sikh today, but my listeners are not all Sikh. So let’s talk about the hoods, because that is one way to get around the beard. Or the fact that let’s imagine any type of mask facial mask does not fit you, for example. And therefore we’re now looking at a hood. But for those people who have been tested some hoods and I’ve got some colleagues who are testing some hoods, they find it that the type of and Doctor Sami, you know, being a periodontist, the type of fine work that we used to do perio plastic work, resin work, things that need good vision and clarity may not be as easy to do and it’s very cumbersome, like we said about the weight as well. The fact that you may have to use a saddle chair and a normal chair with a backrest will not be able to use that. So there’s lots of issues. I’m personally really looking for any solution that will not involve a hood. So I don’t really know I didn’t really finish with a question there. But what I mean to say is, hopefully we’re not going to need to all use hoods, but what advice can you give to those who may need to use the hood and how to do good quality dentistry is even possible? [Sami]
So I think we’re going to have to readapt in many respects, and I think the clinical environment itself needs to be adjusted for the new era that we are now in. I agree with you, for those that are wearing a beard. If the respirators are clearly are not an option for them. So it has to be in the hood. So then you can work backwards from how you’re going to adjust the surroundings to the hood, much more space around the dental chair. I think you see, when I’m operating as an oral surgeon, I stand up. When I’m operating as a periodontist, I sit down. You make a very good point about the chair, I’m in the chair with the back on it, may be something that he might not be able to use anymore. So you think about using the saddle or standing up. The house was mentioned earlier that hood is this there’s an element of distance created. And that distance is a physical distance. And it’s also a psychological distance. We can’t communicate with our patients as well, that badly affects the elements of empathy that we can provide to our patients as we give them a more holistic chairside manner to our approach. And, you know, these are all things that we’re going to have to change the loupes is an issue of the moment and I know that as the leading suppliers in microscopes or loupes are looking at ways to adapt into the to the new needs [Jaz]
And even the scopes are difficult. So I tend to doubt but even the microscope, my colleagues who are testing all this sort of stuff, hoods mostly You know, we’ve got a group of of Sikh people with beards and turbans who are trying to preempt a solution that will allow us to do good dentistry, but also be protected. And there’s a firm that loupes are difficult and microscopes are also finding difficult. Yes, Tarik? [Tarik]
Jaz, we are testing now and working now with industrial products that are designed for industrial applications and trying to adapt them to the healthcare workplace. The marketplace is dictated by demand and need. So already we are as a group working with a couple of respirator manufacturers to evolve and develop some solutions. And that’s been driven by the demand. So if it is going to be, as you say, are likely SOP, and it’s going to be needed within the healthcare industry. Rest assured there will be developments, by dentists, for dentists, by healthcare providers, for healthcare providers. We are innovators we are we have a lot of creativity within our professional industry. And rest assured that there will be some new designs that everyone will be protected, if need be through a respirator, they will have the right solution for them. And most likely it will be developed by a dentist, or at least the development will be, there is contribution by a dental professional within that or a healthcare professional at least. [Jaz]
Fine, but it’s just a lot of concern people thinking about, you know, we know that dentistry will never be the same again, but even to do the types of procedures we used to do for some period of time. We don’t know how long but for some period of time, we may be limited to doing extractions and very basic stuff. What I’m trying to say is that the techniques and the treatments that involve finesse may be difficult to do so early on until as you say, Tarik market responds and comes up with some RPE equipment that makes it conducive to excellent dentistry. [Sami]
We also adapt in our techniques, though, Jaz I mean, you know, as time has gone on, in dentistry, even equipment has changed. And, you know, we ended up trying out new things, learning new techniques, and I think we’ll be forced, if you’d like to do that in this era as well. We have to come together and accept that what we’ve always been doing all along is has to be ready to be re adapted. It’s very difficult for a golfer to change a swing. But we are going to have to learn new techniques. And you know, you’re quite right to mention, you know, a particular group says the Sikhs and Muslims and Jews have a problem with the beards. But it’s you know, previously we’ve had concerns where women wearing Hijab and long sleeves haven’t been able to scrub up in [inaudible], some innovative research response to this, have a thinking outside the box to accommodate their own wishes, but also an element of just being a little bit more fluid to the approach of saying that maybe I will have to just change the way I stand, maybe I will have to change the way I look into the patient’s mouth, maybe there will be different lighting systems, we will have to we have to think about this together. [Tarik]
We’re living in an era where digital scanning and custom made devices are more readily available. So creating a seal around the face, there may be other ways of achieving it. And all you need is, for a close fitting so there are two developments that need to happen. Ways of achieving a seal around the face and working around the restrictions of a person to make it personalizable. And maybe a loose fitting solution, where it is more, it’s conducive for the fine work and the what we need as healthcare providers. [Jaz]
Thank you. I’ve been speaking to some people who’ve been trained to do fit testing up north in New York Region. And they’re covering a huge area. I mean, they’re covering from, let’s say, Yorkshire, Sheffield, all the way up to Newcastle. And they’re driving in between these areas. So with the lack of let’s say, fit testers to fit test, let’s say minimum 60,000 people that’s like 30,000 are dentists and there’s far more than 30,000 nurses. Let’s assume a conservative figure of 60,000, looking to come back to work. And I appreciate that you think there’ll be a phase returned to work. But certainly I think there’ll be some bottlenecks in being able to get fit tested. And let’s say one brand of mask runs out. And then suddenly, we need to get fit tested again for another brand says there’s lots of issues. And I don’t want to get too much into the intricacies of all this. But people will try and get around it and get to work as fast as possible. So this all this preamble is basically, one of my listeners, who really wants to crack on as you know, as we all do, as quickly as possible, asked, Is it possible to or advisable to wear FFP2 that you may not have had an opportunity to get fit tested? Because they’re thinking pragmatically that it might be difficult to. And then on top of that were a face shield, do you think that will give an adequate level of protection, is the question from the listener? [Sami]
Well, I mean, it depends what the personal definition of adequate is. I think we’re all in it together that we want to minimize risk. Of course, a one bit of protection is more or less compared to another bit of protection. Our job here or what where we see our role is to help educate the individual to make their own risk assessments. Indeed, there have been those that advocate not fit testing and FFP2. I’ve seen it. And I think it’s a personal choice. I mean, if somebody wants to know if whatever they’re wearing on their face, be a kitchen towel is it allowing some virus to go down the side. If you want to know the answer, then you need a fit test, except that maybe we might be taking more risks to start with, because of the bottleneck. But the mindset to think that Let’s relax our safety measures is something that I wouldn’t advocate. [Jaz]
Thank you and Kareem, I think I believe you with your vast experience of being on the end of wearing all these PPEs RPEs, Is there anything that you’d like to add to that? [Kareem]
Yeah. Firstly, I also I just want to give just a slightly different perspective on FFP2 and FFP 3, where people are thinking that FFP2 means you know, you can be a little bit more loose with applying it. What people need to bear in mind is that in North America, for example, But they don’t use FFP3s. Okay, so the standard there is FFP2 or N95. That’s their standard. So, forget the thinking that FFP2 is different FFP3, it’s just about the viral filtration efficiency, that’s sort of, that’s the only difference. It still needs to be on to use a respirator to protect yourself from a potential viral exposure, it must be fit tested, if you want to take some potential risks, as we talked about already, okay? So at least a fifth in published studies, and, and third in our data from the people that we fot tested, between 20 to 30% of people, they do not have an adequate protection, if they have not been fit tested. Okay? So it’s up to you to decide if you’re prepared to take that risk. I know, I probably wouldn’t take that risk. Okay. But if you’re prepared to take that risk of not being protected from exposure, potentially, from a patient with COVID, or I should say, at least carrying SARS COVID2, then that’s up to you, but I would be guided by the evidence and by the data, and the evidence currently suggests that’s not a wise idea. [Tarik]
Okay, can I turn, I take a third perspective if that’s okay? [Jaz]
Yeah, please, this was all about [Tarik]
Let’s understand the principle. Right? You don’t have to wear [inaudible], it’s not illegal to practice without respiratory protection. It’s not illegal not to do a fit test. Fit Test is a method to show you what CM you have from the respirator if you’ve made the choice to use one. If you use a respirator, you probably are more protected than using just a surgical mask if there is aerosol with particles, if that particles carries a viable virus, we don’t know the risks. We don’t know what’s in those particles. And we don’t know what’s the consequences of being fit tested or not. All the principles are is or the principle is, if you’re choosing to use a respirator, which means you’re choosing to protect yourself from the particles around you. If you’re one to do that, to the optimum way, a fit test is the way to demonstrate [Jaz]
The next question I have is I’ve heard reports that in the urgent dental care centers, that because of the lack of a PPE in some centers, dentists are being encouraged to wear one FFP3 masks or whatever they using per session. So a morning and an afternoon, and then between patients changing the surgical mask that will go over the FFP3. That may be a pragmatic and practical solution in a moment. Is that something that you think can work for practice that may want to be saving money in the future? Because if the if that’s the current standard of play, can we not continue it like that? Is anything bad about doing that? [Tarik]
If I can highlight a few issues, we’re in unprecedented times, and we’re dealing with a large a large problem of not being having the constant supply, and we’re having to deal with that and care for our patients. They need urgent care. So they need urgent care. We’re on a high peak pandemic with no limited supply at the moment. The Public Health England and maybe that’s I may be incorrect but my interpretation is a respirator should be used for single use in primary care settings. In secondary care settings, if there is a shortage, then it may be and it’s an appropriate setting, then it may be used as a sessional use. I haven’t seen any official document to say that you can use a surgical mask on top from a Public Health England point of view. It is thinking outside the box and it is extending the use of it and I believe that the latest guidance from BAOMS, the British Journal of Oral and Maxillofacial Surgery, advocates that. The problem that we have is the FFP3 is currently in supply are not fluid resistant, and we don’t have many of them. So adding a surgical mask on top offers you that extension, but we also use a face shield on top which offers some protection. Respirators should not be modified in any way. Because the whole point of having a fit test and checking with the respirator is that you wear it correctly consistently every time like you said earlier Right? So if putting a surgical mask does that, does that affect the threat? Or not? I don’t know. does it increase the chance of you when you’re removing the surgical mask for it to dislodge the respirator and break the seal? I don’t know. Does it offer any protection for fluid? On top of having a face shield on top? I don’t know. Does it offer some filtration for the FFP3 masks that have an exit valve and potentially the wearer maybe an asymptomatic carrier, and working with a vulnerable patient or a shielded person and coughs during, does that surgical mask offer some filtration or not? I don’t know. The ideal gold standard going forward would be to have a disposable FFP3, that is fluid resistant. That is not valved. And that is cheap and widely available on the same model that you can get every day with adjustable straps that comes in different sizes, then we would have solved the problem in dentistry and healthcare and manufactured in the UK. And comfort. Yes, and manufactured in the UK. And conforms to the quality standards of the British Standards of 149 or whatever standard. So if we have a UK made solution that passes a test that is cheap for us to use per patient, per procedure that’s easy for us to wear, comfortable for us to wear that we can adjust the straps, that comes in small, medium and large. That is fluid resistant, then I would buy that and wear that. And probably I’ll be, whether I wear and I need it or not. I probably now choose to wear it if it is readily available and economically makes sense to me. [Jaz]
Should we be switching to reusable PPE? So some of the masks that looks like one of the main ones, I believe that’s what they tend to look like. Is that something that we should be thinking about instead of having to constantly worry about supply demands and whatnot, Kareem, I believe you may be well positioned to talk about that. [Kareem]
Yeah, I mean, listen, there’s obvious advantages. There’s obvious disadvantages as well. But there’s obviously advantages to having a reusable one, actually, in the long run, it’s more cost effective. So if you’re thinking of one of the reusables, it costs anywhere between 30 and 50 pounds, without having to replace the filter, of course, because there’s an additional cost of having to replace the filter intermittently. And if you compare that cost to a single disposable FFP3 masks that we commonly use in the NHS, they’re in the range of five to seven pounds. So immediately, you can see that there is a cost benefit there. Okay?o there’s a cost benefit number two, because it’s reusable, you do not risk running out of supplies and needed to be fit tested in the next type of RPE that your employer provides you, okay? So you’ve got it, you fit test on it, you know it works, you use it thereafter, okay? And number three, it’s you can keep it for one individual or it can be shared amongst individuals if it’s clean. So for us and certainly with what I do, we have reusable RPEs, that I keep my own one, I have my own one that I’ve been fit tested on that I look after, that I care for, that I check the filter on regularly. I have an idea. I’m not worried that I’m going to run out of supplies, I’m not worried that I’m going to need to be refit tested again. So there’s obvious benefits to them. There’s some drawbacks, of course. The drawbacks are, they’re bulky, they’re large, they need to be cleaned. And of course, you must remember that the whole process of doffing these is a much more challenging process than doffing a disposable because a disposable, you carefully take it off your face with your eyes closed and drop it into the bin. But with these, you’ve got to be very, very careful because you’re not dropping it into the bin, you’re going to be grabbing it there’s two straps that need to be pulled out. You’re going to be grabbing it and then you need to be cleaning it. The cleaning process itself poses potential theoretical risks. There’s no data to support this, but it’s all theoretical risks that you may be dispersing any virus that’s on the RPE itself. So you’ve got to clean it. And what we do is we clean ours. I clean mine myself, just because my my own peace of mind once a day by disassembling it and cleaning it properly as per manufacturer’s instructions, different manufacturers have different instructions, and you’ve really got to adhere to those instructions. So there’s pros and cons of using reusable versus single use, to my mind, having the, you know, the benefits of having the reusable, for me, personally, at least, outweigh the risks and the end of the drawbacks of the bulkiness and the cleaning. [Jaz]
Sami and Tarik, as dentists, Do you think reusable is the way forward? [Sami]
Well, I think that all that Kareem just elaborated on is equally applicable to us. The one thing I would add about the bulkiness is this thing is like stuck to your face. And dentists in particular. We’re working a good What is it 6, 7, 8 hours a day at least with this thing stuck to our face, I don’t know how many patients we’re going to be seeing in the post COVID area compared to how many patients we used to schedule in our dairies before. But that in itself is going to be a challenge and they’ll undoubtedly be you know, facial markings, marks on your face after you don it could possibly cause scarring I don’t know. It’s something that we’re going to have to consider when we’re selecting which type of protection that we’re going to use and, and in dentistry also, certainly, for oral surgery, for example, I sometimes hear patients every 20 minutes for goodness sake, but I don’t think I’m going to do that again. But incorporating in that schedule now is the donning and doffing and the inspection and cleaning. So it’s so many factors now to put into the melting pot that we previously didn’t consider. [Tarik]
I have access to both. And I’m fortunate to have access to both. Certain procedures, I would wear the reusable respirator, certain scenarios, I will use the disposable. For example, yesterday I had an anxious that lady that needed an impacted third molar removed, so it’s likely to be an AGP. And I chose to put a disposable one. Because I didn’t want to add another fear factor. It is probably the way forward. And as a fit tester, a variety of sizes, for a variety of scenarios is probably the way forward, both all clothes fitting respirators are designed for a short period of time. And the Health Safety Executive expects a wearer to wear it comfortably for less than an hour. So after an hour, you’re probably more likely touch it, you’re more likely adjust it. So they’re not designed for extended use both of them. And as part of our fit testing. The first thing we check, can you put it correctly consistently yourself? Yes. Can you comfortably wear it? and work with it? Yes. And then we did a fit test. And we’ve had people that put on our disposable and think No, this is too much for me. We’ve had people that stay on the whole training session with one. We’ve had people try on the reusable and say, yeah, that’s fine. I don’t see any problem with this. I actually do this when I do my DIY work, or DIY, DIY work at home and I’m used to it, and some people put it on and say no, I’m never gonna wear this. I hate the look of this. That’s not for me. And we have to be prepared for that. And respirator is a way of controlling the hazard. There are other ways of controlling the hazard. There is, dare I say not doing AGPs, dare I say controlling the hazard in another way. And don’t forget that respirator is the last resort in the [puzzle]. So all other things that we do is the right thing to do. Respirators should be considered as the last resort in protection, controlling the hazard. [Jaz]
Sami with your ethics. background, I want to ask you who should be paying for this? Private practice, who should pay for let’s say all these FFP3s because I’m increasingly seeing some principals, trying to plan the future charge of this to make the associates buy their own PPE. Where do you see this? [Sami]
I might have a law and ethics education that’s certainly far bit for me to give an opinion on how people should be running their own businesses, but I’m a principal as well. So I understand the issues here. I mean, it’s a minefield, I think the law states that employers need to be providing a safe working environment for their employees. And sadly, in this new era, that means providing them safe air to breathe. That’s a really, really sobering thought. But then equally, you know, principals haven’t traditionally provided loupes for dentists, they haven’t. Some provide them with uniforms, some don’t. It’s something that’s going to have to be an internal decision. [Jaz]
Your opinion? [Sami]
I haven’t even answered that question for myself and my own staff yet, it’s going to be a really tough one, [Tarik]
No matter who pays for it, we need to make sure that we’re protected. And we have the right equipment that is, if it is a respirator, then ideally should be fit tested. And we need to and then if the dentist pays for it, then does the nurse pay for it? And if they pay for it themselves, do you quality assurance? Do you make sure that it’s working? Do you make sure that’s fit tested? So quality is I think what’s important. Paying for it, And who pays for it is obviously an important question as well. But for me the quality and the safety of everyone involved And I’m sure we will have a professional guidance on this from the people that are experts in this. [Jaz]
Okay, fine. So gentlemen, the final question I have is, with us potentially Fingers crossed, hopefully getting back to work. And the inevitable increased demand for Fit Test is because based on what you’re saying, it sounds like for your safety, for the safety of our staff, it’s really important because we don’t know exactly what we’re dealing with just yet we need more research. So for the time being, I think that what I’m sensing is that it’s something that we should be getting done proactively once the decision is made about SOPs. So, should there be more people getting trained for fit testing, was it involved? And just give us a flavor about that? [Tarik]
So I think yes, knowledge is key. We need, if we need fit testers, we need professional fiy testers, not industry fit tester. Training in becoming a fit tester, there are two methods qualitative or quantitative. It is both a it’s a skill, it’s an art and it’s a science. So with that, any skill, art and science need just not that you can’t just grab it by reading a book, you can’t grab it by just watching a video, you need to be trained, educated, you need to practice that skill, you need to have it observed, you need to reflect on your performance and be supervised to gain that competency in a safe manner. And that’s what we’ve been doing thus far. Not just training, but reflecting, supervising, mentoring, and ensuring that the competency is gained safely whoever provides a fit testing, it’s a legal requirement for them to be competent in doing so. There is a British safety. There is a accreditation scheme and being accredited as a fit tester is that gold standard of fit testing, but that’s for industry. In healthcare, we need well trained professionals that are able to do it within our context, understand our environment, understand what is needed, and I think we are as dental professionals, not just dentist but all of the dental professionals are ideally suited to be our own fit testers if we need it in the future. [Jaz]
Brilliant. Sami, did you want to? [Sami]
I would sort of agree with that so much in that you know and the time gone by firemen and construction workers have had to receive an element of training and the level of fit testing that’s appropriate to their environment, and the world and healthcare has just changed overnight now. So whilst a great majority of what they have overlaps into our environment, there’s a substantial amount that doesn’t, and therefore what is missed by generic training, I think targeted and focused training that is relevant specifically to our professional and we’ve just talked about. So when we were talking about sitting in the chair or a saddle, we’ve talked about the loupes, we’ve talked about the empathy of chairside and communication with the patient, when you’re appearing differently than when you did in the last appointment, but then six months ago, these are all things that the construction workers haven’t needed to address in their field of work. So model has brought all that into one basket, in order to make it more focused and relevant. [Jaz]
Kareem any anything you’d like to add? [Kareem]
Can I add, I wanted to add something Jaz, if I may. There are some personality traits that suit or qualities of a person suited to become a fit tester, you need to be pay attention to detail, you need to be conscientious, you need to give confidence to the person that you’re fit testing. And you need to not just want to tick the box. I have attended about six training courses, all of them accredited, and I’ve had different experiences. We all know training can be different and can be, the same content can be given by different people but the result can be different. Also, we know that six people can attend the course and their competency after the course can be different. So not everybody that is trained to be attend the course, to become a fit tester is a good fit tester. At the end of it, you need to have a process to ensure that the person at the end of that training journey is competent. [Jaz]
So gentleman, What’s the difference between a fit test and a fit check. [Kareem]
So a fit test is, as we discussed earlier, an employer’s responsibility. And it’s a way of assessing the performance of a respirator. And whether it’s adapt, does it conform, or create a seal with that person’s facial features that lasts for two years and it’s only for that particular model of respirator. And it’s not valid if the person loses weight, or gain weight, or anything that affects the scene area, including significant dental work, that makes it invalid. A fit check is the responsibility of the wearer. And that’s something that they should do every time they don the respirator. And it gives them confidence that they’ve don it correctly consistently. And they’re trained to do it for each type of respirator, it’s a different technique. [Jaz]
So everyone who gets fit tested and starts wearing and FFP2and FFP3 for example, needs also to everyone needs to be a fit checker, a proficient fit checker? [Kareem]
Part of the training part of the your fit testing is to be trained to fit check. So that’s why that’s one of the reasons why fit testing is so important. Because it teaches you to fit check, there are some people that think that I can fit check without having fit testing. So a fit check is effectively you put the mask on, you suck in, and if it sucks in effectively, and if it feels like there’s a seal, then then you should have confidence in that. But that’s, to my mind, that’s probably insufficient. Because you need to have quantitative, not just qualitative, but quantitative and objective measures to demonstrate that, that you have an effective seal whereas fit checking is purely subjective. And it carries significant user error. [Sami]
So we were setting the standards, I hope, in dentistry, fit testing, should be the required risk management strategy. But it’s not the case in hospitals? Kareem? [Kareem]
Well, I think that there has been some some institutions across the UK who have effectively said that you should that fit checking is sufficient. And that probably comes down to the fact that there’s probably too many clinicians or health care workers that need fit testing, but they do not have the capacity to fit test everyone and so therefore they’ve made pragmatic decisions to meet healthcare demand. People should just fit to test- fit check, sorry. And I think that if you have, if you’re taking responsibility for your own health and well being, then I don’t think personally that that would suffice. And I would encourage employers to really consider the, you know, doing what’s best for their employees as well [Sami]
We’re quite fortunate, I think, in primary care dentistry, that we do have much more of a level of autonomy to make our own decisions in this regard. So it’s not going to be as sort of victims of a departmental policy of a large organization or in dental practices can make their own risk analysis in this regard. [Jaz]
Brilliant. And can I just get some rough dates? Sammy, when do you think I’ll be able to do some composites again? [Sami]
Well, the last time I did a composite was about 25 years ago. And I certainly hope I’m not going to be doing one anytime soon. But let’s look, let’s be positive about this. Let’s be positive about this, I know there’s lots of politics involved. And I know, there’s questions as to which advice we should be following. As Tarik has alluded to, I think it’s going to be a phased re entry back into the profession. And I think we’ll probably be doing more of non AGP procedures to start with. I’m not going to put a label on anything. I would hope, I would hope that we’re practicing dentistry in July. [Tarik]
Can I add we, first of all, when it is safe for you, when it is safe for the nurse, when it is safe for the patient, when it’s safe for other patients in the practice to do so. Or also perhaps when we have the evidence that it is safe for you, for the nurse, for the patient, for other patients in the workplace for you to do so. Also, I hope or last message is for us to go back to work. We need confidence from the profession. We need guidance from the profession, we need that coordinated approach from the profession, we need the patients to have confidence in us. We need the CQC to have confidence in us and our workplaces. We need our workforce to be confident in their ability to do everything safely, that they are protected, that they’re their patients are protected, and that their loved ones are home or protected. I have resistance from my loved one saying no, don’t go to work. Because with all this fear around, I don’t want you to bring it home. How would you feel if I felt ill? So I think two ways. One, we should already be working out we should be preventing disease, we should be reaching out to our patients, we should be engaging with them. And we should be helping the national response and taking the burden out of the 111 triage. I know I spoke to a GDB this morning. And that was taking calls, despite his normal hours not being open on a Saturday just to take that burden off 111. So that little, the as much effort that we all do as a profession, the quicker we will get to normal, whatever what that normal might be. [Jaz]
Well, I’m here is hoping that it will be ASAP. Gentlemen, it’s been great to have you on the podcast today. Lots of facts. So much needed, because there’s lots of speculation going on. Thank you for all the hard work that you guys doing behind the scenes, and of course on the front line as well, really on behalf of the nation. Thank you guys. [Sami]
You’re welcome, Jaz, thank you very much for having us. It’s great for us to get together and chat and to be thought provoking in this way. We see ourselves as just a very, very small piece of the jigsaw puzzle. And we’re happy to help anybody that reaches out to us. I’m happy to put our email address out there, which is email@example.com. So that’s spelt info, I-N-F-O @dakatra, which D-A-K-A-T-R-A .co.uk. Any one that has any questions, by all means we are, our doors remain open. [Jaz]
Brilliant. Well, thanks very much, Gents. [Kareem]
Thank you for having us. [Sami]
Thank you. [Tarik]