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Sir, as an orthodontist working in specialist practice I read the paper by Shah _et al_.1 with particular interest and a feeling of rising frustration. We are continuously improving our

cross-infection control and the focus of this paper on orthodontics is relevant to this process. One should always aim to continuously improve standards for our staff and patients, but it

feels like a seismic shift is approaching in the regulation of cross-infection control. As this happens, I have yet to come across examples of risk:benefit analysis, cost:benefit analysis,

and in these days of global warming, carbon costings? These are three elephants in the room which this paper, as with all of the others I have read which quote various studies and committee

reports, fails to mention. My suspicion is that, if they were there, they would have quoted them. Furthermore, they do not discuss from where the money will come (elephant number 4!), and

how many fewer patients will be able to have treatment as a result? As I read about such proposals, I ponder how recommendations for change come about. It seems that committees of experts

get together to write new advice, but in the modern climate of blame one can imagine that members would, above all, want to create rules which have the least likelihood of future blame being

laid at their doorstep. Cost:benefit doesn't seem to come into the equation, unlike the deliberations of NICE. As a small example of a reasonable question regarding cost:benefit is the

use of masks. This paper quotes guidelines that a mask's main function is to protect from splatter and that they should be changed for every patient. No distinction is made between a

patient having a surgical procedure or a dental exam or an elastic changed on an orthodontic appliance. As an orthodontist, I wear a mask for a session at the moment, and tie it so that I

can raise or drop the mask without touching it. It takes me half a minute to change a mask and a box of 50 masks costs £11.45. Following new guidelines, if I see 50 patients in a day and if

surgery overheads are, say, £100 per hour, then the total extra cost for my nurse and I just to change masks for every patient is £72.90 per day. If I work five days per week for a 45-week

year, the additional cost just for compliance in mask wearing, is more than £16,000! Who will pay and what is the benefit? I dread to think what the additional cost of all the guidelines in

the offing will be when one considers the requirements for additional space, staff, equipment, time, and energy consumption, and I can anticipate the position of the PCT that there will be

no additional funding for these regulations - they will force the change but they won't pay for it. This is bound to affect the quantity and quality of publicly funded treatment

available. I would like to see the BDA force a debate with government on these related issues as a part of implementation. Even if the decision is to follow exactly the same path, it might

ease the frustration associated with the massive changes that will ensue. REFERENCES * Shah R, Collins J M, Hodge T M, Laing E R . A national study of cross infection control: 'are we

clean enough'. _Br Dent J_ 2009; 207: 267–274. Article  Google Scholar  Download references AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * By email, P. Huntley Authors * P. Huntley View

author publications You can also search for this author inPubMed Google Scholar RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Huntley, P. Who will

pay?. _Br Dent J_ 207, 520 (2009). https://doi.org/10.1038/sj.bdj.2009.1092 Download citation * Published: 12 December 2009 * Issue Date: 12 December 2009 * DOI:

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