The risk manager

As dentists return to routine dentistry, Prof. Martin Cormican spoke to the Journal about the thinking behind the expert guidance they will be relying upon, and what the future might look like for dentistry post Covid-19.

Prof. Martin Cormican is an extremely busy man these days. As a member of the Government’s Coronavirus Expert Advisory Group, a subgroup of the National Public Health Emergency Team (NPHET), he works with a multidisciplinary group of experts to monitor and review national and international research and developments in relation to Covid-19, providing expert advice to NPHET, the Health Service Executive (HSE) and others. The Group has played a key role in the advice and guidance on Covid-19 preparedness and response, including the preparation of guidance for dentists as they return to routine practice. An enormous amount of work went on behind to scenes to produce this guidance. Martin explains that, as is the case with all infection prevention and control (IPC) guidance during the pandemic, the guidance for dentistry was prepared by the Antimicrobial Resistance Infection Control Division (AMRIC) of the Health Protection Surveillance Centre (HPSC), with input from a number of dental stakeholders: “We had really helpful conversations through the process with the Chief Dental Officer, Dr Dympna Kavanagh, and with David O’Flynn, the Dental Council Registrar. We also had conversations with HSE dentists, and with a dentist nominated by the Irish Dental Association”. Martin says that there were two documents, the second of which had even more extensive stakeholder engagement, including reference to international publications and guidance documents on dentistry, which were provided to the expert group by dental stakeholders: “We worked through all of those documents, and they were discussed with the representative nominated by the Irish Dental Association and with other dentists”. It’s a lengthy and involved process, with particular challenges: “One of the challenges across the whole of the guidance development around Covid is that the evidence base in many cases is weak. If there is a clear evidence base then it’s pretty straightforward because you go with the evidence. [With Covid] there isn’t always a clear consensus of expert opinion internationally so you end up trying to make reasonable judgements in that setting”.

Consensus

Martin says that all those involved worked very hard to reach a consensus on the guidance for dentistry, and he is satisfied that this was achieved on the vast majority of issues. One of the main sticking points, however, was addressing concerns regarding aerosol-generating procedures (AGPs). For Martin, this again is not an issue exclusively for dentistry, but he acknowledges that it was a crucial one to resolve: “The same issue has come up right across the board in healthcare services, and people take very different views on it. By and large, IPC professionals see AGPs as one element to be considered, whereas for people who are not IPC professionals, the emphasis on AGPs is much greater. It’s not that IPC professionals discount AGPs, it’s just that we see them as one element of a much bigger series of risks, in particular contact and droplet, which we would see as being the major issue for transmission of this virus. The issue around AGPs is the issue that we all had to work quite hard on to come to as near a consensus as we could”.

He understands dentists’ concerns, and says the aim was to address the whole spectrum of risk, again while working from a less than certain evidence base: “We do know that dental procedures generate a lot of aerosols and we know that aerosols can contain microorganisms. One of the big things for me in developing the guidance was trying to find evidence that people who work in dental practice are at a higher risk of respiratory virus infection than the general population, and I wasn’t able to find much evidence of that. I believe that the kind of guidance we put into the document, if carefully implemented, goes a long way towards managing the risk. But there is no zero risk, and the biggest things in my experience that go wrong are not the high-tech things like aerosols. When I’ve seen colleagues get infected at work, it’s almost always, in my opinion, more likely to be related to fatigue and distraction: you forget to wash your hands, or you forget to bin your gloves, or you touch your face. A huge part of infection control is the human factor. If we can do whatever we can to make sure that people avoid extremes of fatigue, and avoid distraction, and that they have time and opportunity to be careful and follow basic procedures, that’s where 90% of the safety is”.

Prof. Martin Cormican giving one of the many Covid-19 media briefings on RTÉ News.

Back to practice

In the early days of the crisis, most dentists chose to close their practices to all but emergency cases. The advice issuing from the Dental Council at the time was to operate as normal; however, in the absence of clear guidance, dentists were deeply uncomfortable with this. In a Liveline interview given at the time, Martin spoke about the fact that he had not wanted to close dentistry in the initial stages of the restrictions. Asked to elaborate on this, he points out that while the question was asked in the specific context of dentistry, his response was the same as it would be about almost any other healthcare service: “It’s always necessary to consider the consequences. Closing down a service sometimes seems like the obvious way to manage your risk, but that has consequences for patients first and foremost, but also consequences for practitioners. Broadly speaking, across the whole range of measures that are taken in response to the control of infectious disease, I would always emphasise the need to consider what are the benefits of the measure, what are the consequences, and what are the potential harms, and try to make sure that those are balanced”.

Dental practices are now reopening in line with the new guidance, and dentists are looking forward to a return to treating patients. However, all of this is happening alongside the very real fear of an increase in infection rates leading to another shutdown. Martin says that guidance in relation to specific essential services would depend on a range of factors, not just the reproductive index of the virus – the ‘R’ number with which we have all become so familiar: “Clearly, all of us are at risk of getting Covid in our ordinary lives, but the question for us as healthcare workers is: are we at an additional risk related to our work? The thing that I think is really important to watch out for is evidence of Covid infections in dental practice that appear to be related to workplace exposure. The nature of the work dentists do involves a lot of contact with oral fluids. Wearing gloves and hand hygiene is an important part of managing that risk. But when we get infection in healthcare workers, and we have seen a lot of infection in certain categories of healthcare workers, it’s often very difficult to know what it was they got infected from. We say in the guidelines that it’s really important that any cases of infection associated with dental work should be properly reported and recorded. And the reason for that is that we try to get an early signal if anything is going wrong. If the processes we’ve put in place for controlling the risk of infection in dental practices are working, and if dental services can be provided with safety for the patient and safety for those who deliver the services, then the reproductive rate is not the thing that would drive [a shutdown]”.

He returns to his earlier comments about the importance of maintaining essential services during the pandemic, while seeking to balance the risks involved: “Even at the height of the pandemic, certain services which are essential didn’t stop because they are so fundamental to the functioning of society that you can’t stop them – you have to work with the risk. Oral health is so fundamental to general health that the long-term absence of dental services to me would be catastrophic. I’m not NPHET obviously, and the Government and NPHET may take a different view, but I would be very careful about shutting down essential services because all of that has consequences for people’s health and well-being, and indeed for people’s livelihoods. Finding a way to sustain both of those things in the pandemic would appear to me to merit a very high priority. One of the things said in conversations with stakeholders about this is that dentistry wasn’t zero risk before Covid. There’s an increment of risk associated with Covid, and how do we manage that? It’s difficult I think, and we will continue to learn – our understanding of what we need to do next year will probably be better than it is now”.

Lessons learnt

Martin says that much has been learnt from the discussions around the guidance for dentistry, particularly from his perspective as an IPC professional: “In the early stages of a newly emerging disease, it is very difficult for everybody, I think, to look at the risk and to try to focus on the evidence, because for all of us, particularly if we see colleagues or hear of colleagues getting sick, that has a very powerful effect on how we look at risk. Across the healthcare sector, if you’re the person who’s doing the procedure and your perception is that you are at risk, sometimes people in that situation find it very difficult to have an outsider from their profession like me saying, well, actually, I’m not sure I quite agree with your evaluation of risk. That’s entirely understandable, and it’s one of the challenges for me as an IPC professional. One of the things that was useful was the dialogue around that. I hope that it was clear to colleagues that even if we didn’t always agree at the start, we were both concerned about the risk, and we were both trying to manage the risk, and none of us were discounting the risk”.

For the future, there’s no doubt that it’s still an evolving situation, and as we try to adapt to this ‘new normal’, Martin is keen that the fundamentals are not forgotten: “Based on previous experience with other pandemics, what tends to happen is that in the early stages, people sometimes overestimate the risk, and in the later stages they underestimate the risk and start to become too casual about it. What we’re trying to do is get people to a stage where they’re following a certain level of precaution consistently. That would be my big caution going forward: don’t drop your guard because the basics of infection prevention and control apply to all patients at all times, and are probably the most important thing in keeping patients and healthcare workers safe. The additional things we do for those who we recognise as being at risk add value, but the biggest safety net for most of us most of the time, and for most patients most of the time, is that we’re following the basic rules as consistently as we can.

“Covid is not going to go away. I don’t foresee that we’re going to have a Covid-free Ireland in the near to medium term. The challenge for us is going to be: how do we deliver healthcare services in an environment which has been changed by Covid?”

Prof. Martin Cormican

Martin graduated from NUI Galway Medical School in 1986. He trained in Ireland, the UK and the USA, and was appointed Professor of Bacteriology at NUI Galway and Consultant Microbiologist in 1999. He is director of the Galway University Hospital National Microbiology Reference Laboratory services, and was recently appointed as National Clinical Lead for healthcare-associated infections (HCAIs) and antimicrobial resistance (AMR). His research interests include antibiotic resistance and food-borne infection. With colleagues he established a Centre for Health from Environment at NUI Galway to promote research and advocacy on the central role of the environment in enabling people to live fulfilling and joyful lives.