On 4 January 2021, Chris Whitty, the Chief Medical Officer for England, told BBC Breakfast, 'I am confident we will go back to normal life as it was before at some point. That's not in doubt. That's the life we want to lead'.

But should we question Professor Whitty's premise that, 'a life that is basically the same as it was before' (COVID-19) is 'the life we want to lead'? Dentistry is amid difficult times, but opportunities are emerging from the energy of innovation and the need to problem solve. Healthcare is currently on a roundabout, moving swiftly in circles and the roads leading from that circuit, ultimately taken by choice or instruction, will sculpt the next normal. The dental profession is practical and imaginative but the risks of unintended consequences in the next normal will need insightful management.

This article explores how responses to the challenges of a dangerous pandemic may shape dental practice in the future, and the importance of attention to the unintended dentolegal consequences. Unmet need for treatment, potential skill loss, safety fears, rapid exploitation of virtual communication, financial pressures, reconfiguration of the fabric and systems of dental practices, legal requirements and the fragility of wellbeing all need careful attention. What positives can we exploit and which negatives do we need to watch for?

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© Tempura / E+ / Getty Images Plus

Who knew?

At the height during 2020, Dental Protection answered three times the normal daily numbers of requests for advice from members. At the core is the expectation by the public and service providers of timely, accurate communication of relevant information. Dental practices are both recipients and conduits for their patients. They have been expertly supported by swift actions of, and collaborations between, professional organisations at many levels often involving younger colleagues whose insight is powerfully essential. The products of such positive working relationships, built out of crisis, are undoubtedly greater than the sum of the parts. Sustaining such positive alliances will benefit the profession in the next normal.

UK dentistry, recognised at last as a frontline service, has been agile, resourceful and resilient, managing ambiguity in ever-changing and country-variable guidance. Most practices have adjusted, offering assessments, urgent care and active treatment. Simultaneously, in October 2020, half of Dental Protection's UK dental members reported their mental wellbeing had deteriorated and a similar number were pessimistic about the future.

The material risk of the NHS being overwhelmed has prompted our medical colleagues to join together, facilitated by the Medical Protection Society, to call for emergency legislation to protect doctors and nurses from inappropriate legal action when dealing with circumstances outside their control.1 In a Dental Protection survey of nearly 500 UK dentists, conducted during October 2020, 40% said fear of investigations arising from difficult decisions made during COVID-19, or disruption to care, was having most impact on their mental wellbeing. This evidence was presented to the GDC and indemnifiers have welcomed the GDC's recent guidance to Case Examiners which emphasises that the context in which complaints arise should be taken into account.

Reflecting on decisions made under pressure

The return to the next normal may, indeed, bring difficult conversations if patients feel they were inappropriately previously described limited choices and nudged into decisions they now regret. The size of the iceberg of complaints is not yet known. There is a difference between the likelihood of a claim of negligence in these circumstances and the more likely investigations of ethical breaches.2 Time allows reflection and also a distortion of the past reality. Dentists doing their best in challenging circumstances may need to draw deeply on their communication skills (and records) - and seek assistance from their defence organisation - to provide reassurance that they acted in their patients' best interests.

We are great at IPC

Each new threat of transmissible infection introduces further Infection Prevention and Control (IPC) measures that dental teams implement swiftly and efficiently. We have addressed these hurdles on many occasions and are exemplars within healthcare organisations. Little do patients realise that we have successfully protected them from viral cross infection in our practices for years. Patients and regulators expect that each set of new measures remain for perpetuity. Those of us old enough will recall wondering if wearing surgical gloves was a passing fad for which exceptions could be justified but there is a bleak comparison between the inconvenience of a pair of gloves and the distraction and unpleasant awkwardness of full PPE. Scientists tell us that a successful vaccination programme may not be enough to see the universal end of social distancing and mask wearing. This will do nothing to alleviate the fears for some patients running far into the future that dental practices are hotspots for transmission of COVID-19. It is neither professional nor ethical to insist that a patient signs a disclaimer waiving any right to redress if she thinks she became infected in the practice. A far more effective risk prevention measure is proactively to communicate about how the practice follows published guidance and is committed to providing a safe environment.

The stark fragility of oral health

New IPC safeguards will permanently slow down our efforts to repair and maintain our communities' oral health. The stark fragility of oral health in the UK is also being revealed. The necessity for many for regular servicing to stay in good health, free from pain and dysfunction, previously a financial means to an end for many practices with loyal patient bases, has exposed the vulnerability of our previously presumed success.

Apparently, extraction of teeth was included in Tim Peake's training as an astronaut. How many of us would be able to sign off all our patients for an eight month stay in the International Space Station without worrying that Major Tim's (illegal?) skills might be needed?

Primary care dentistry has always provided same day access to treatment for acute pain and infection. This expectation has carried its own risks. Time in busy appointment books for the clinical management of urgent needs requires planning - something highlighted in recent years by the drive for effective antibiotic stewardship in dentistry and by regulatory investigations of complaints of failures to manage to a patient's pain. This remarkable service has been simply accepted and expected without appreciation by the public or governments for years - until it stopped. Dental and medical practices have reported abusive behaviour when patients find their expectations cannot be met. It is difficult to predict whether this level of frustrated and frustrating intolerance will subside or not. Enhancing communication training and support for team members in anticipation will continue to be a high priority for wise practice leaders who want to minimise the damaging distraction of complaints.

'You're (not) on mute'

Good news includes the explosion of digital communication across society including those traditionally thought to be computer wary. Patients appear to be willing to engage in remote consulting: a time saving and convenient facility for both parties when used appropriately. The next normal will see virtual triage and review used extensively along with follow up consent and appointment planning video-discussions so that patients are allocated correct surgery time. The opportunities for involving team members in virtual one-to-one 'checking in' oral health education are exciting and time-resource efficient. There is no shortage of sound risk management advice about the unintended consequences of communicating with patients through digital media. Agreeing internal protocols can address these.

Someone else will see your patient at some point

Home working is here to stay for many. Previously long commuters are already changing to dental practices to nearer home or simply to one that will see them. Dentolegal advisers know this is a risk management hot spot. New dentists have to manage others' treatment modalities, successes and failures, frequently without relevant information. With consent of the patient, dialogue between the two clinicians can often reveal helpful background and a calmer transition for all.

Do it once, do it well

To any observer, financial sustainability of dental practice is a serious, fundamental concern. It is not the place of this article to explore the frictions and perverse incentives of NHS contracts and financial assistance available to private practices, and the challenged business relationships between practice owners and associates, except to highlight that these will continue to be a source of tension for registrants trying to do the right thing. Dentistry has much to offer if there is a genuine will to 'put the mouth back in the body' and the publication of the FDI's Vision 20303 flagging the health, societal and economic impact of oral conditions is timely. The challenge for funders and regulators is to appreciate that dental teams will do their best if their behaviour is not manipulated by fear of disproportionate sanction or targets. The challenge for the profession is to stick to its professional guns and, whenever possible, do the right thing

Accelerating the positives

We are seeing collaboration and teamwork like never before. Empowered and skilful team members have been involved in developing and the governance of Standard Operating Procedures with system changes made swiftly and efficiently. Better IT is available to all - ready to be further exploited. There is no shortage of excellent on-line learning opportunities and, finally, there is a will to place wellbeing front and centre. In the midst of draining challenges, there are positives to emerge. Let's not lose them. â—†