Anyone reading the BDA's advice since the COVID-19 pandemic began will have understood the benefit of a triage interview with patients in order to make the best use of time and resources when face to face treatment is indicated.

Furthermore, a risk assessment of the patient and the treatment required allows the clinician to plan the most efficient allocation of valuable surgery time between episodes of low risk procedures and higher risk aerosol generating procedures (AGPs) that require a higher standard of personal protective equipment (PPE).

The Standard Operating Procedure (SOP) documents provided by the four chief dental officers recognise that their guidance requires local interpretation according to individual surgery premises, the layout and capacity.1 The dental team is expected to use their clinical judgement when applying this guidance. In that respect, the choice of PPE when working with patients has to be matched to the level of risk perceived by the team.

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.

Although it is recommended that AGPs should currently be avoided where possible, there will be occasions when such treatments are in the patient's best interests and the dental team will need to prevent aerosol transmission, using a disposable, fluid-repellent surgical gown (or waterproof long-sleeved protective apron), gloves, eye protection and suitable respiratory protective equipment (RPE) such as an FFP3 respirator (or FFP2 when these are not available).

The respirator worn by those undertaking or assisting in the procedure should have been previously fit-tested. Fit testing of PPE may be performed by dental staff with appropriate training, or third party contractors that specialise in such services.

The SOP guidance advises contractors to inform their employers liability (EL) insurer that all staff undertaking aerosol generating procedures are required to be fit tested for appropriate PPE, to ensure their EL insurance cover is sufficient. In addition, dentists should check with their indemnity provider if they are performing the fit testing for their own staff or that of other local dental contractors, again to ensure they have adequate cover. It might be helpful if the GDC would recognise fit-testing as part of the practise of dentistry - just as they do for the management of other medical emergencies. This might allow a more uniform response from the indemnity providers who with one exception have not responded to the need for dentists and practice owners to have clarity on this matter.

So it was reassuring to receive an email from the BDA Indemnity team confirming that they recognise fit testing as an essential part of safe dental practice together with an assurance that it is covered under the definition of dental services included in their policy and at no extra charge.2

BDA indemnity cover allows policyholders to fit-test respiratory protective equipment (RPE) for dental staff in their own and other practices. Plus, the practice owner's policy will cover an employee in their own practice to do fit testing.

Those wishing to become a fit tester should be trained to the standards set by the British Safety Industry Federation and be accredited as a fit tester for RPE.3 There is an obligation to maintain your competence by regular refresher training and updates just as you would for life support. A record of RPE training should be stored as part of your continuing professional development. The BDA provides more information about fit testing in its returning to work toolkit.4

Each dental practice operates in a local community and in many cases have been part of that local fabric for many years. Patients build up huge amounts of trust in those practices and create strong bonds with them. This toolkit is about strengthening those bonds and reinforcing goodwill.

At a time when the footfall through the practice is likely to be lower than before there will be financial implications for the patients and clinicians alike. Many patients will face a degree of hardship until the UK economy recovers and there is likely to be a drop in the discretionary spend on elective treatments.

In addition, there will be additional costs to the dentist from cross-infection protocols required to mitigate the risk of COVID-19. Let alone the drop in hourly income that will flow from treatments and the associated donning and doffing of PPE.

The experience of indemnity providers during previous episodes of economic downturn has usually been a rise in the number of claims and complaints that they are asked to manage on behalf of the dental profession. Hopefully things will be different in the face of this pandemic but you can probably see there will always be an element of temptation for some patients to see if they can reduce the cost of treatment by getting a refund by complaining about the work that was done or the way in which it was provided.

The best way to counter those tactics is to reduce the level of patient expectations from the start. By under-promising what you know to be possible you will subsequently be seen to over-perform when you complete the patient's treatment.

Private hospitals may well bill their patients for all the disposable items used in their treatment, but your patient may be irritated to see an extra figure to cover two sets of disposable PPE.

Over time, it is likely that PPE costs will come down again whilst the requirement to wear higher grade PPE may change depending on further research into dental aerosols and immunity for dental teams either developed naturally or through vaccines.