A news item on Radio 2 today highlighted a letter from the Chief Dental Officer (Barry Cockcroft) advising dentists that all files and reamers (instruments used in root canal therapy) should be made single use to reduce the risk of spread of variant Creutzfeldt-Jakob Disease (vCJD).
The debate about the spread of this disease via root canal instruments has been running for several years now and is based on the concern that dental pulp tissue could contain the tiny particles that spread this disease (prions) and that these may not be destroyed by current sterilisation processes. Previous risk assessments for the transfer of vCJD infectivity via dental surgery have concluded that the risk is low. That said the the Spongiform Encephalopathy Advisory Committee (SEAC) have maintained a watching brief and have now concluded “It is unclear whether or not vCJD infectivity can be transmitted via endodontic files and reamers. However, given the plausibility of such a scenario and the large number of procedures carried out annually, it would be prudent to consider restricting these instruments to single use as a precautionary measure. Since sufficiently rigorous decontamination of these instruments is difficult, single use of these instruments would eliminate this risk, should it exist.”
Early findings coming from research carried out by the Health Protection Agency show a possible pathway for TSE – Transmissible Spongiform Encephalopathies, the group of prion diseases that iinclude BSE, CJD, vCJD and scrapie to be spread via dental tissue in mice. It is these two findings that have lead to this advice being given.
It should be stressed that this is a letter of advice only and cannot be counted as a definite guideline to current best practice. There has been no response, as yet, from the General Dental Council or NICE, the institute for clinical excellence. It should also be stressed that there has been not one single case world wide reported of the disease being spread this way.
The implications of the advice are massive in terms of cost, both financial and environmental and as the title suggested all but removes this type of treatment from NHS care on financial grounds. To complete one root canal filling can take two visits and involve upto three sets of instruments (hand files, rotary files and special drills called Gates Gliddens). Each set costs around £20-£25 plus VAT, making a potential cost of £75 plus VAT extra per case. Currently, under the new NHS contract a dentist is paid £46 for a root canal filling. Clearly they will be unable to provide this treatment if they are paid less than the cost of the instruments alone (they would also need materials, staff and overhead costs to be met long before they could take a salary from the fee).
At StoneRock Dental Care I provide many root canal fillings and see a great many patients from various practices in the surrounding areas. We have always provided above and beyond what is required for our sterilisation procedures and are confident that we have protected our patients at all times. If this advice becomes procedure then the costs will increase for this work. I have resisted making this decision on this basis but will wait eagerly for the next response to today’s suggestion. In the meantime if any patient is concerned and wishes to purchase a set of instruments that are to be used on them only then we will happily do this for them. The instruments will be stored in sealed packets for their use and can be used as a maximum in 5 procedures (giving 2-5 root canal fillings per patient, which is hopefully more than enough).
If you want to read the full article by Barry Cockcroft, Chief Dental Officer you can find it on www.dh.gov.uk