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COVID-19 and Dentistry: Challenges and Opportunities

COVID-19 and Dentistry: Challenges and Opportunities

The coronavirus disease outbreak in 2019 and 2020 (COVID-19) had closed down around 198,000 active dentists and dental specialists in the USA. As governments in different countries allow the resumption of dental care, worries and talks have emerged regarding how to provide a safe oral healthcare, considering the nature of the virus and how easily and rapidly it may spread during common dental procedures. However, dentists have come to a realization of looking beyond treating urgent dental care needs and start planning for the resumption of routine dental care, and finding safe and creative ways to provide service to patients who are anxious to come to the dental clinic. This will definitely be an extremely challenging task given the uncertainty of when the pandemic will be resolved.

The virus behind COVID-19, SARS-CoV-2, is present in nasopharyngeal and oral cavity of infected patients. It is believed to be transmitted primarily through infected secretions such as saliva and respiratory secretions or their respiratory droplets. Also, emerging evidence shows that normal breathing and talking can produce small droplets that can possibly spread the virus and remain suspended in the air for several hours. The rapid transmission of the virus in many communities, the potential for pre-symptomatic or asymptomatic individuals to transmit the virus to others, and the close contact of the dental healthcare workers to the patient’s mouth and throat, all contribute to the high risk for dental personnel to become exposed and to transmit the virus to other patients and staff. Some dental procedures may result to aerosol generation, which could further increase the transmission risk to dental employees and patients through inhalation or contact with contaminated surface.

Challenges in Dental Practice

Dental professionals are already familiar with other health issues and corresponding risk assessments in order to reduce risk, and with implementing Standard Precautions for minimizing the spread directly or through cross-contamination. Preventing the spread of SARS-CoV-2 requires new and improved health protocols and management strategies that may differ from those used before the pandemic. COVID-19’s incubation period can range from 2-14 days, and, while the virus is known to be highly transmissible when patients are symptomatic, transmission can still occur before the symptoms become apparent. Thus, even asymptomatic patients should be considered as potential carriers, and routine screening should be implemented for both patients and staff. This helps to ensure that symptomatic and exposed individuals stay home for the safety of everyone in the office.

Current guidelines suggest that elective care for patients with confirmed or suspected COVID-19 should be delayed until the patients meet the criteria for dental service. For patients with confirmed COVID-19 who need to receive emergency dental care, treatment guidelines have been developed and recommended by various organizations, such as Centers for Disease Control and Prevention (CDC) and the American Dental Association (ADA), to prevent virus transmission as much as possible. The dental workers are advised to:

Perform procedures in a negative pressure room for aerosol-generating procedures

Follow standard, contact, and airborne precautions

Consider taking extraoral radiographs instead of intraoral

Limit the number of dental healthcare providers (DHCP) present during the procedure

Use a dental hand-piece with anti-retraction function, four-handed dentistry, high evacuation suction and rubber dams to minimize droplet splatter and aerosol generation.

Minimize the use of ultrasonic instruments, high-speed handpieces, and 3-way syringes

Perform endodontic procedures with dilute (1%) solutions of sodium hypochlorite to extend supplies

Use resorbable sutures to eliminate the need for a follow-up appointment.

Disinfect surfaces with EPA-approved chemicals and maintain a dry environment.

Wear an N95 or equivalent or higher-level respirator such as a disposable filtering facepiece respirator, a powered air-purifying respirator, or an elastomeric respirator; eye protection (e.g. goggles, reusable face shields); gloves; and a gown.

In the Philippines, on the other hand, the Philippine Dental Association (PDA) has issued their version of guidelines to avoid the spread of COVID-19. It also urges a no-contact screening procedure, based on the recommendations of the DOH, WHO, and Center for Disease Control and Prevention (CDC). The recommended guidelines are as follows:

Dentists and all staff must wear the prescribed personal protective equipment (PPE) including protective eyewear, surgical mask, disposable caps, and disposable gloves.

Dentists should screen patients by phone before confirming an appointment to avoid close physical contact with persons infected with COVID-19.

Elective procedures are not allowed.

Only immediate concerns such as pain, infection, oromaxillofacial conditions, or trauma can be addressed by dentists. Patients for such urgent dental concerns are required to fill up a screening form, including their companion.

Patients with temperature higher than 37.3°C or 99.14°F and with respiratory disease will be referred to a hospital immediately.

Although not stated in the aforementioned guidelines, providing safe dental care during the pandemic may require dental workers to change their workflow patterns and clinic layouts besides ensuring personal protective equipment supplies. Such changes may lead to increased costs, which could further result to financial and operational issues. Also, wearing PPE can be hot and uncomfortable. It can be a hassle especially when doing certain procedures. These conditions may create several challenges, which may lead to increased errors in dental practice. Knowledge-based active errors, rule-based active errors, or skill-based active errors can all jeopardize the safety and quality of care given to patients. Managing important deviations from conventional practice, while under additional budgetary pressures, stress and time constraints, may increase the risk of failures during dental care.

Opportunities

The global pandemic has greatly affected how dental care can be safely delivered, and it will most likely stimulate permanent changes in how dental care is delivered. The dentists will have to consider numerous unanswered questions, such as whether the workflow and layout of dental clinics should be permanently changed, and whether expanded PPE is warranted for care of all dental patients. The COVID-19 pandemic may also speed up the adoption of innovative dental workforce models, including dental therapists with at least 3 years of training and provide a limited scope of treatment, such as prevention, fillings, and treatment for periodontal disease, with the help and guidance of a dentist. In a recovering economy, the lower cost of dental therapists may foster their adoption or more independent scope of practice.

The COVID-19 pandemic offers several opportunities for dental researchers to focus on extremely major issues. Significant research concerns may include evaluating the costs and benefits of the use of expanded PPE and changes in dental practice workflows, developing and assessing innovative approaches to minimize aerosol generation during dental procedures, testing and validating tele-dentistry models, and evaluating alternative dental workforce models, such as dental therapists.

What do you think about the pandemic’s impact on dental practice? Do you have other challenges and opportunities in mind? Drop your comments below!

#onlineschool Dentistry challenges opportunities

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