Sir, has the covenant of AAA decreed during the COVID-19 pandemic dismantled the years of stewardship built into dental practice? During Lockdown 1, my last six months in a busy mixed practice seemed to feature all my referrals bouncing back to me. I initially fought off requests from patients for antibiotics and explained adamantly that 'antibiotics are not pain relief'. It was immensely disheartening to call these patients back who could not attend the UDC unless they had completed a course of antibiotics. For irreversible pulpitis cases, I was asked to give antibiotics, knowing that these would not affect pain relief, the only indication being to progress the referral to the UDC. The template even asked for the prescription number to check for my poor prescribing.

In July, the truth dawned on me regarding the effect our prescribing was having. I recall three patients who contacted the practice via 111, asking for help with their dental pain, but noted 'please, no antibiotics'. Initially I found this surprising as it is the opposite of usual patient requests for medical management. These patients explained that they had been prescribed antibiotics from an emergency dentist and acquired C. difficile infection resulting in hospital admission and further burden upon the NHS. They were fearful of having more antibiotics. The risk of C. difficile infection is not commonly discussed with patients and it was frustrating to reactively state this very real risk to patients following their adverse experiences. These patients subsequently and understandably refused further medical management and progression of their UDC referral was halted, placing them in a dental no man's land with limited prospects until practices reopened.

All this did not feel consistent with 'putting patients' interests first' and I feel the draconian adherence of the UDC referral to the stringent AAA 'guidance' was limiting patients receiving required help. Indeed, many remained in pain until we could see them in our practices having acquired appropriate PPE. The resultant admission of patients with C. difficile infection into NHS hospitals will also have added unnecessary pressure onto hospitals, concurrently cancelling oncology cases due to the pandemic. It seems negligent to have these effects overlooked for the sake of ticking a box on a referral form and having patients' best interests in mind. Perhaps we can change the COVID-19 AAA covenant to Analgesia, Advise, Appropriate antibiotics? I am currently working in South Wales in secondary care and spend one day a week in a fantastic UDC that has eliminated the requirement of the patient having to complete a course of antibiotics to qualify for emergency treatment. I hope we can see all health boards follow suit.