An Indelible Impact

In CDC's guidance, the agency stresses that dental settings must balance the need to provide necessary services with that of minimizing the risk to patients and dental healthcare personnel and explains that COVID-19 is thought to spread primarily between people who are in close contact with one another through respiratory droplets produced when an infected person coughs, sneezes, or talks. CDC also notes that the virus has been shown to persist in aerosols for hours and on some surfaces for days.^5,6

According to the results of an Inside Dentistry reader survey, since the COVID-19 shutdown, 60.79% of the responding dental offices significantly increased their infection control and personal protective equipment (PPE) protocols, and another 32.01% reported that they slightly increased those protocols. The remaining 7.19% of respondents reported that they already had stringent protocols in place.

"Dentistry has been mislabeled as it pertains to infection control," suggests Roger P. Levin, DDS, founder and CEO of the Levin Group. "We have been a leader in this area since the mid-1980s when the AIDS crisis hit, and everyone started regularly using masks and gloves. A dental office is one of the safest places that a person can visit."

Strict compliance with industry regulations and workplace safety rules has always been a priority in dentistry. The profession has seen its share of infectious disease scares in the past, including those related to HIV/AIDS and SARS. Historically, bloodborne pathogens have been of greater concern to the profession than airborne diseases. "We learn in dental and dental hygiene schools that we should be cognizant of airborne pathogens, but there is a major chasm between the expectations in school and how things are truly implemented in ‘the real world,'" explains Katrina Sanders, RDH, BSDH, MEd, RF, a dental hygienist in Phoenix, Arizona, who lectures nationally on dental hygiene continuing education. "In the middle of 2020, dentistry is being forced to become more aware and make some changes."

Indeed, the link between oral health and overall wellness may uniquely position dental healthcare providers to help lower the risk of severe complications associated with COVID-19 infection. According to an article published in the British Dental Journal, oral hygiene should be improved during a COVID-19 infection in order to reduce the bacterial load in the mouth and the risk of a bacterial superinfection. The article recommends that poor oral hygiene be considered a risk factor for COVID-19 complications, particularly in patients who are predisposed to altered biofilms due to diabetes, hypertension, or cardiovascular disease, and notes that because some of the bacteria present in patients with severe COVID-19 infections are associated with the oral cavity, improved oral hygiene may reduce the risk of complications.⁷

"This is dentistry's opportunity to assert itself as part of the team of healthcare providers who are working to mitigate the risk of COVID-19," explains Sanders. "This is a culture shift where we have the opportunity to be recognized within the medical community as patient educators, communicating with our patients what we know about risk factors and protection and asserting our role within the broader healthcare landscape."

Proper PPE and sanitization procedures, as well as the provision of up-to-date information and adequate training for personnel, are critical to preventing the transmission of infection in the dental office. Furthermore, office policies and operating protocols are being revised to support infection prevention efforts, and building a more holistic understanding of each patient's healthcare is more important now than ever before.

Upon Arrival

Across many industries, from restaurants to doctor's offices, businesses have reduced capacity and are serving fewer clients.^8,9"During the phase following the shutdown, scheduling has changed to avoid overlap and time in the waiting room, and more time has been allotted for each patient due to screenings, changes in treatment to avoid and minimize aerosol generation, operatory turnaround, and other requirements," explains Fiona Collins, BDS, MBA, MA, an international presenter of continuing education and member of the Organization for Safety Asepsis and Prevention. "That is challenging for all offices because schedules must be adjusted to allow for extra time, and particularly challenging for dental offices backed up with patients now receiving treatment that had been delayed."

According to Rob Ritter, DMD, a general and cosmetic dentist in Jupiter, Florida, "A reduced capacity directly impacts patients. For patients who put off a visit until something hurts or breaks, when something happens, they won't be seen as quickly as before because we're seeing less people daily."

When patients do show up to dental offices, they are met with new protocols that are designed to mitigate the risk of COVID-19 transmission and reassure them. Some practices are sending out "welcome back" letters and calling patients to communicate these precautionary changes. The ADA's in-office patient registration procedures recommend the use of screening forms, masks, temperature checks, wipes, and sanitizer.

"It's concerning that asking our patients about their overall health, including screening for overall immune health, is a ‘new concept' or an intermittent task for some dental healthcare professionals," laments Sanders. "We are a part of the medical community, and what we do as practitioners is impactful to our patients' overall wellness. Having a patient's complete and updated health history, including a nutritional survey and genetic history, is critical."

Donald S. Clem, DDS, diplomate and chair of the American Board of Periodontology and a practicing periodontist in Fullerton, California, emphasizes that administrative staff should not be excluded from using proper PPE. "They can be subject to infectious contact with patients or even other staff through community spread that comes into the office," he says. "For example, cloth masks should not be relied on by any member of the clinical or administrative team. Requiring all team members to wear procedure masks supplied by the office is the best strategy for controlling the quality of the protection. As healthcare personnel, the entire office must participate in a well-thought-out, effective airborne transmissible disease mitigation plan."

Once in the operatory, some recommend using a preprocedural mouth rinse.¹⁰ Previous studies have shown that SARS-CoV and MERS-CoV were highly susceptible to povidone iodine antiseptic rinse. Therefore, a preprocedural mouth rinse with 0.2% povidone-iodine might reduce the viral load of the coronavirus (ie, SARS-CoV-2) in saliva.^11,12Alternatively, a mouth rinse that is 0.5% to 1.0% hydrogen peroxide may prove effective because hydrogen peroxide has been shown to efficiently inactivate the coronavirus on inanimate surfaces.¹³

During Procedures

After the preprocedural protocols are followed, appropriate PPE must be selected based on a risk assessment and the procedure that will be performed. The US Department of Labor's Occupational Safety and Health Administration (OSHA) categorizes work tasks associated with exposure risk using levels from "lower" to "very high," and the performance of aerosol-generating procedures on known or suspected COVID-19 patients has been designated a very high risk.¹⁴

Regarding aerosols, rotary dental and surgical instruments, such as handpieces, ultrasonic scalers, and air/water syringes, create visible sprays with droplets that can contain water, saliva, blood, microorganisms, and other particulate debris. Surgical masks protect the mouth and the nose's mucous membranes from droplet spatter, but they do not provide complete protection against the inhalation of airborne infectious agents.¹⁵

The actual viral load present in the aerosols created by dental procedures and the viral load required for COVID-19 transmission are still debated.^16,17 "If you stop using an ultrasonic scaler, the risk of generating aerosols is lower," notes Levin. "You can also use rotary devices at slower speeds."

"In fact, there is a lot that can be done to mitigate the risk from aerosols," explains Eve Cuny, MS, associate professor, director of environmental health and safety, and assistant dean at the University of the Pacific's Arthur A. Dugoni School of Dentistry. "This risk can be impacted by measures taken to reduce dispersion, such as the use of high volume evacuation or other suctioning devices, a rubber dam, and other measures," she continues. "It can also be impacted by the air flow in the facility, the location of return air vents, and whether or not the facility has windows that can be opened, among other factors." The provision of adequate training in transmission precautions and the proper donning and doffing of PPE is also essential to infection control in dental practices.

"It isn't possible to create a sterile environment in the dental office," explains Collins. "It's really about following recommended protocols for managing the environment and source management as well as all of the other guidance provided during the COVID-19 pandemic. That includes avoiding and mitigating dental aerosols."

Although the literature on aerosols was plentiful even before COVID-19, there is an unfortunate lack of information about the minimal infectious dose and quantified risk of contracting COVID-19 from aerosols. "There is a myriad of devices available at this point but limited information on their usefulness in mitigating aerosols," says Collins. "That doesn't mean that devices shouldn't be used but rather that more independent research is needed for devices, about the variables in a given environment, and regarding how to control these variables." In the meantime, dentists can minimize the use of ultrasonic instruments, high-speed handpieces, and 3-way air/water syringes to reduce the risk of generating contaminated aerosols.¹⁸

"In dental hygiene, it is possible to do scaling and root planing with hand instruments instead of ultrasonics, but it is almost impossible to avoid the use of an air/water syringe in providing dental care to patients," explains Cuny. "This has led the profession to look for ways to minimize the risk from aerosols through either source control (ie, reducing the amount of aerosols or the length of time that aerosols are generated) or other types of engineering controls and PPE."

In addition to PPE and device awareness, alternative procedures may be warranted to avoid riskier situations. For example, instead of using intraoral imaging, extraoral imaging modalities such as panoramic radiography or cone-beam computed tomography (CBCT) can sometimes be indicated to avoid gag or cough reflex. When intraoral imaging is necessary, a double barrier can be used on sensors to reduce the potential for perforation and cross contamination.¹⁹

For Follow-Up

COVID-19 has disrupted business as usual. In a recent Inside Dentistry reader survey, 38.57% of responding dentists indicated that infection control and PPE measures have been "significantly" disruptive to the office workflow, and another 52.5% said that they have been "somewhat" disruptive. This can be especially true when simple postoperative follow-up management is required. Fortunately, remote consultations using teledentistry have been shown to both increase patient compliance and establish stronger doctor-patient relationships.²⁰

Teledentistry can provide an innovative solution to help enable dental care during the current pandemic and beyond.²¹ Teledentistry can be easily incorporated into routine dental practice, and it offers a wide range of applications, including remote triaging of suspected COVID-19 patients who require dental treatment and reducing the unnecessary exposure of healthy or uninfected patients by decreasing their in-person visits to already burdened dental offices.²²

Teleconsultation, telediagnosis, teletriage, and telemonitoring are all components of teledentistry that can play an important function during the COVID-19 pandemic.^23-25 For example, during the early stages of the pandemic, investigators demonstrated the successful use of WhatsApp and telemedicine in making a differential diagnosis of oral lesions.²⁶ Similarly, in an early pilot study, telemonitoring appeared to be a promising tool for the remote monitoring of surgical and nonsurgical dental patients, especially regarding the reduction of costs and waiting times.²⁰

For many, the incorporation of teledentistry into routine practice has provided an extremely useful alternative to face-to-face visits during this pandemic. Although teledentistry can complement the existing compromised dental system during the current pandemic, it is not legal in all states, and in the states where it is legal, it's primarily used for very specific purposes. "I think teledentistry will be very popular for orthodontics, where you can easily do virtual consults, or for postoperative follow-ups, which normally have a less than 50% show up rate," says Levin. "We also see a role for it in oral surgery, but at the Levin Group, we view it as ‘early stage' in dentistry and believe that its use will gradually increase over time. There is a limit though, as dentistry will, for the foreseeable future, be primarily driven by in-person interaction with the patient." It's important to verify with relevant state professional licensing boards the requirements for becoming a qualified provider who can legally offer teledentistry services.²⁷

The initial reaction to COVID-19 in the United States resulted in a large-scale shutdown of the dental healthcare sector. The financial implications were enormous. At the end of March 2020, in a poll conducted by the ADA Health Policy Institute, 69% of the responding dentists reported that their collections were less than 5% of what was normal prior to COVID-19.²⁸ And, alarmingly, data from the US Bureau of Labor Statistics indicated that dental practices accounted for more than a third of the 1.4 million healthcare industry job losses in April 2020.²⁹

An April 2020 survey conducted by Net32 Inc. found that 70% of the responding dental practices had already implemented layoffs and that only 11% had retained all of their staff at full pay.³⁰ In addition, 70% of the dentists surveyed indicated that they were planning to rely heavily on government assistance programs to help them get through the shutdown, and 46% admitted dipping into their personal savings to help their practices. Nearly every practice surveyed reported that PPE purchases had a financial impact on their businesses; 46.95% reported a "significant" impact, 44.8% reported "somewhat" of an impact, and only 8.24% reported a "negligible or non-existent" impact.

"These expenses are sustainable long-term, but you have to become a student of accounting," explains Ritter. "You have to understand your numbers better than ever before. You need to understand your fixed costs and what expenses you're taking on for additional PPE. Then, you may have to increase your fees to compensate, or at the end of the day, you might be making less."

Although the profession of dentistry itself has been hit hard during this pandemic, the impact of COVID-19 on the general community is also playing a big role in practices' finances. Patients often cite financial barriers as reasons for not being able to see a dentist during regular times, and COVID-19 has brought about mass unemployment throughout the nation. Utilization of preventive oral healthcare services by unemployed individuals can be impeded by both the loss of employer-sponsored dental insurance and the reduction of their overall financial resources, making out-of-pocket oral care too expensive.³¹

Our understanding of COVID-19 and its implications is rapidly evolving; however, the future remains uncertain. This pandemic has clearly brought about significant changes to practice. "Just as we saw lasting changes after the emergence of HIV/AIDS, I do think we'll see lasting changes with the COVID-19 pandemic experience," says Collins. "Even if there is an effective vaccine and sufficient individuals are vaccinated, I believe we will continue to look at the dental office environment differently in the future."

Clem agrees. "Although some of the enhanced PPE requirements may be loosened, such as N95 masks, other mitigation controls, such as greater attention to air quality, will most likely be incorporated," he says. "As technology makes these engineering controls more accessible, methods of improving air quality, like filtration and UV disinfection, will likely be considered by more dentists."

New knowledge, skills, and technology will help dental offices adjust to whatever the future holds. Oral health is a major factor in overall health; therefore, improving oral health can have great systemic implications for the overall quality of life of individuals and society as a whole.³² In this regard, it is critical that dentists are able to continue to offer safe services and procedures for their patients.

As we learn more about the coronavirus, dental practices must stay abreast of the current knowledge to continue to provide adequate training and protect their teams and patients through screening and preventive measures. This will allow oral healthcare to be provided while mitigating the spread of this novel infection. Dental healthcare personnel should regularly consult their state boards and state or local health departments for updated information, including the degree of community transmission and any region-specific requirements or recommendations.³³