Sir, what constitutes an aerosol generating procedure (AGP) is in dispute between the British Orthodontic Society (BOS) and the Office of the Chief Dental Officer, England (OCDO). The guidance from the OCDO is that using a slow handpiece for caries removal with high volume suction does not produce an aerosol,1 while the BOS' view is that for removing composite after a fixed appliance debond, it does.2

The BOS has therefore advised its members that all orthodontic procedures could be undertaken with personal protective equipment (PPE) appropriate for non-AGP, but should include the use of a fluid resistant surgical mask (FRSM) and high volume evacuation (HVE), as well.3 The BOS' view is that the corollary use of a rubber dam would be limited in its practical application where multiple teeth are concerned and being technique sensitive, many orthodontists would be unskilled at present.2

These are understandable concerns, but neither problem is insurmountable. Almost three decades ago, the use of a rubber dam while debonding fixed appliance ceramic brackets was recommended as a means of protecting a patient's airway during a process that could result in the disintegration and aspiration of a radiolucent ceramic fragment.4

While some orthodontists might need ab initio training in rubber dam placement, for others a refresher session should suffice. It would be no more time consuming or challenging than having to learn how to don and doff AGP PPE and it would generate less contaminated waste.

Should orthodontists wish to enhance cross infection control during composite removal, they could follow the BOS' advice and assess the procedure's risks on an individual basis and undertake all necessary precautions they deem to be appropriate.3 Bar donning AGP PPE, they could otherwise enhance the BOS' FRSM and HVE recommendations, by including the use of a preformed rubber dam, bearing in mind that while HVE and rubber dam are individually effective at reducing splatter and microbial contamination, together their effects become synergistic.