The Profound Impact of COVID-19 on the Dental Profession
Neeraj Panchal, DDS, MD, MA; and Mark Wolff, DMD, PhD
The coronavirus disease (COVID-19) pandemic has impacted the world in unprecedented ways. It is clear that this pandemic, unlike any public health challenge in recent memory, has the potential to fundamentally alter the delivery of many healthcare services, including dentistry. As evidence-based information on COVID-19 continues to emerge, this article serves as a means to disseminate current opinions, management strategies, and the impact of COVID-19 on dentistry.
The CoronaVIrus Disease 2019 (COVID-19) altered society and the practice of dentistry dramatically.1,2 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) originated with transmission from a bat species to a human in Wuhan, China, presumably in December 2019 and rapidly spread to start a global pandemic.3,4 The World Health Organization declared a global pandemic on March 11, 2020.5 There had been two recent, limited outbreaks of zoonotic origin coronavirus, Severe acute respiratory syndrome (SARS) in February 2003 and Middle East respiratory syndrome (MERS) in September 2012. These viral outbreaks, although deadly to those infected, did not have as significant of a global impact as SARS-CoV-2.3
The SARS-CoV-2 virus primarily spreads via respiratory droplets or particles, such as those in aerosols, when a person coughs, sneezes, speaks, or breathes, and is within six feet of another individual. There is some evidence that the virus may also spread beyond six feet or via respiratory droplets falling on surfaces, and individuals touching a virus-laden surface then subsequently touching their nose, eyes, or mouth. The virus is more contagious in individuals who are symptomatic, but the virus can also spread from asymptomatic individuals. The epidemiologic feature of potential spread among asymptomatic individuals made COVID-19 extremely challenging to control, and resulted in the importance of social distancing, universal mask wearing, and frequent hand hygiene.6
COVID-19 symptoms are variable, but often include fever, chills, fatigue, loss of smell (anosmia) and taste (ageusia), coughing, difficulty breathing, diarrhea, and body aches. Approximately 80% of patients have mild symptoms. Patients with mild disease without evidence of hypoxia or viral pneumonia are often managed with supportive care at home and quarantine to prevent further spread. Patients with more severe disease resulting in respiratory failure, sepsis, cardiomyopathy, cardioembolic events, or multi-system organ failure among many other sequela are managed in a hospital critical care setting. Advanced age and medical comorbidities increase the risk of developing severe illness.7
COVID-19 started to have a profound impact on the population in the United States in March 2020. Rapid spread of the disease resulted in the shutdown of schools, businesses, elective healthcare services, and many governmental services due to limitations in personal protective equipment (PPE) and hospital capacity.2 Most dental care centers were initially closed and were only available for limited urgent care needs of the population. The Occupational Safety and Health Administration (OSHA) classified dental providers in the very high risk category for potential exposure to the disease due to the inability to maintain an interpersonal distance and the exposure to saliva, blood, and other fluids during evaluations and aerosol-generating procedures.8,9 The COVID-19 pandemic significantly transformed routine operations in community dental offices, universities, and dental organizations.
Community Dental Practice
During the COVID-19 pandemic, community dental practitioners received direction by their local state health departments on the ability to practice dentistry.10 Initially in the first few months of the pandemic many states closed all dental care except for urgent issues. This resulted in difficulties in access to dental care especially in scenarios with acute dental infections or in the evaluation and management of potentially malignant pathology.2 Dental offices being closed resulted in furloughing of many dental staff and personal economic hardships for dental offices and their staff.
Many dental practices donated their PPE supplies to hospitals due to community shortages of this resource. Since dental providers perform aerosol-generating procedures, additional safety precautions such as fit-tested N95 masks or power air-purifying respirators (PAPRs) were recommended to reduce the risk of occupational disease transmission. For proper utilization of a respirator, OSHA mandated that dental offices required scheduling of fit-testing of masks and/or purchase of PAPRs. The limited reserve, production capabilities, distribution, and concern for defective or counterfeit PPE supplies left many dentists with an inadequate supply to see their usual patient base.
During the shutdown, teledentistry became more prevalent.2 Many dental practice acts expanded to permit teledentistry and dental insurance companies broadened their acceptance of teledentistry encounters for reimbursement. Initial evaluation of dental emergencies with a virtual video visit or telephone visit allowed dentists to manage acute problems with pharmacologic techniques, such as antibiotics and analgesics, and triage when there was limited availability of dental office hours.11 The teledentistry visit also allowed dental practitioners to screen for some of the common symptoms of COVID-19, including questions related to recent travel, COVID-19 diagnosis/symptoms, COVID-19 contacts, or attendance of events with large groups of people.12 Elective treatment was deferred for patients who failed the screening. More urgent issues in potentially SARS-CoV-2 infected patients were referred to centers with appropriate engineering controls and PPE. Despite the significant risks and limitations in PPE, many dentists cared for their patients so they could manage their patients' urgent issues.
As the rates of COVID-19 and hospitalizations decreased and availability of PPE increased, dental offices reopened with significant alterations in May through July of 2020.13 Dental offices altered schedules to reduce the number of patients. Oftentimes patients would wait in their cars instead of the waiting rooms. Waiting rooms were cleared of magazines, posters, and decorations to improve cleaning.14 Waiting room chairs were separated to maintain a six feet social distance. Upon entering the dental office, patients and employees were screened for COVID-19 symptoms and temperature checks were performed. Handwashing and/or hand hygiene with alcohol-based hand sanitization became universal for all individuals entering the office. Any surfaces or objects touched by an individual were required to be sanitized, as SARS-CoV-2 can persist on surfaces for hours or up to several days, depending on the type of surface, the environment, the humidity and temperature.14,15 The use of extraoral radiographs were accepted to reduce the potential risk of disease transmission with coughing and gagging that may occur with intraoral radiographs.16,17 Plexiglass barriers, distancing of office chairs, and universal masking were additional methods to reduce staff exposure in the office.13 Staff were encouraged to avoid shared group meals and minimize social interaction.
There was significant concern for performing procedures near the oral and nasal cavity due to risk of transmission, especially during aerosol-generating procedures. Dental providers commonly utilize rotary and ultrasonic instrumentation with irrigation systems resulting in aerosol production.18 Enhanced air filtration engineering controls with negative pressure rooms were prohibitive for dental providers due to the significant costs, limited availability, and the construction time necessary. Due to this limitation, dentists attempted to reduce the amount of aerosol exposure by utilizing rubber damn isolation,19 specialized suctioning systems, four-handed dentistry, air-purifying devices, high-efficiency particulate air (HEPA) filters, faceshields, protective gowns, and avoidance of procedures causing coughing.1,3,9 Dental providers were encouraged to do hygiene procedures without ultrasonic equipment, which causes significant aerosol. Patients were also asked to perform pre-procedure rinses with agents to potentially reduce the bioburden of virus particles to reduce aerosol risk.20,21 The dental team had to learn to wear appropriate PPE in protocolized fashion when performing procedures that create aerosols. The steps for donning PPE often included: (1) shoe covers, (2) appropriate respirator/masks, (3) eye protection/face protection, (4) hand sanitization, (5) first pair of gloves, (6) waterproof gown, and (7) second pair of gloves. The steps for doffing PPE often included: (1) hand sanitization with gloves on, (2) removal of shoe covers, (3) removal of gown, (4) removal of gloves, (5) hand sanitization, (6) removal of eye protection/face protection, (7) removal of respirator/mask, and (8) hand sanitization.19
Many hospital-based procedures required COVID-19 testing. However, due to a shortage of testing capacity, there were significant limitations in the availability of COVID-19 testing for dental providers until later in the year. The primary technique for COVID-19 testing is in the form of real-time polymerase chain reaction (PCR), to detect the virus primarily from respiratory samples of nasal swabs. The turnaround time for PCR testing ranged from 6 to 72 hours and was significantly limited. Rapid methodologies of testing emerged in the summer of 2020, however their initial accuracy was uncertain, availability was limited, and costs were high. (Testing methodologies are described later in this issue.) Most dental offices performed procedures without any pre-procedure testing.13
The initial economic impact on dental offices was profound. The closure of offices led many staff members and dentists without a means to earn a living. Government Paycheck Protection Programs (PPP) helped to reduce the economic burden for dental offices by providing loans to continue wages for the staff and doctors. When offices did return to operations, there were significant increases in overhead related to PPE costs and reduction of patient volume to create spacing. Dental offices had to be mindful of appropriate air exchange times in procedural areas especially when aerosol-generating procedures were performed. Many patients were hesitant to see a dentist due to the theoretic concern of disease transmission when not wearing a mask and being in close proximity to dental providers and staff.
The long-term impact of reduced access to care and patient hesitation to seek routine care resulted in many worsened maladies from delays in care. The lack of routine periodontal care and caries management resulted in more advanced disease. Similarly, the lack of oral cancer screening performed during routine visits potentially placed patients at risk for missing oral lesions and delayed diagnosis and treatment.2 The psychological stress associated with the COVID-19 pandemic also resulted in an increase in patients sustaining cracked teeth from parafunctional habits.22
The Food and Drug Administration approved an emergency use authorization for three different vaccines (Moderna, Pfizer, and Johnson and Johnson) to reduce the severity of COVID-19. Dental staff were considered essential healthcare workers and were approved to receive the vaccine in the earliest stages. However, since many of the vaccines were distributed and administered through hospital systems, some dental personnel not affiliated with the hospital system did not receive priority. As of March 12, 2021, depending on state regulations, approximately 28 states have allowed dentists to administer vaccinations, and the federal emergency declaration under the Public Readiness and Emergency Preparedness Act authorized additional providers, including dentists and dental students. The growing movement of dentists to vaccinate is a critical public health need and federal agencies have fortunately authorized vaccination by dentists.23
Dental education was transformed by the COVID-19 pandemic. Dental school clinics, lecture halls, and laboratories were initially closed. Dental educators quickly adapted to ever-changing guidelines associated with the pandemic to create a virtual dental curriculum. Communication was a key to success at dental academic institutions. There was significant psychological impact associated with the pandemic, and it was necessary for academic leaders to provide clear, open communication with students, staff, and faculty to impart direction. Academic leaders had to balance the safety of patients, students, staff, and faculty, maintain continuity in education, and quickly transform operations for continually changing local and state regulations.24
The pandemic forced dental educators to embrace learning technologies. Online lectures and seminars became the norm due to social distance guidelines. Dental educators utilized both synchronous and asynchronous methods of teaching to ensure that the pandemic did not disrupt the quality of the didactic education. Group and independent learning with use of learning technology tools became an important aspect of curriculum. Though didactic curriculum was able to be transformed to a remote delivery of content, limitations in virtual reality systems and haptic technology made it difficult to transform more hands-on training. There was significant stress associated with transforming to remote education as both students' and faculty members' comfort level in using the technology was varying. Methods to perform equitable and secure assessments of knowledge required academic institutions to create new examination protocols.
The pandemic had profound impact on clinical dental education during March, April, and May; students graduating from the class of 2020 were impacted in completing graduation requirements in many regions of the country. There was significant concern in students providing direct patient care in dental school clinics and extramural rotations. The Commission on Dental Accreditation allowed modifications in clinical requirements and practice due to the COVID-19 pandemic. Many dental institutions quickly transitioned to a virtual clinical curriculum. Case presentations and group discussion on management of the cases were emphasized. Many requirements and competencies were completed via virtual means, and some clinical requirements were completed after local state regulations allowed elective dental care. Dental licensure examinations were also altered as a result of the pandemic. Live-patient examinations transitioned to mannequin-based licensure examinations. Commencement activities and dental residency externships and interviews were also transitioned to virtual modalities.25
Just as community dental practices suffered economically, dental schools also had significant budgetary concerns. The decrease in clinical revenue played a profound impact on dental school finances. Many schools implemented furloughs, early retirement plans, reduction in salaries, and hiring freezes. The additional cost increase of PPE, schedule alterations, and limitations in aerosol-generating procedures further limited clinical productivity. Many institutions increased clinical hours to reduce the number of students and patients in the building at one time. Furthermore, academic institutions, as many in the community, had challenges with child-care and elderly-care availability for parents and caregivers. The initial shutdown of elective procedures and dental offices required dental schools to create multidisciplinary emergency clinics to serve the emergent dental needs of the local population and patients of record. Academic dental institutions in addition to local and federal regulators and organized dentistry served as a resource for many dentists in the community.
The pandemic altered the recruitment and promotion of faculty. Due to budgetary constraints, in general, there was significant limitations in hiring new faculty. Some faculty were required to take pay reductions and work extended or altered hours. Based on institutional policies, many dental schools allowed more flexibility in the tenure and promotion process. The research productivity of faculty was significantly altered as many laboratory/animal-based researchers were unable to access their laboratories unless their research was related to COVID-19.
Burnout and psychological stress were a common occurrence.13 Academic dental institutions required further support of students, staff, and faculty.10 The alterations in usual workflow and processes along with social isolation had a remarkable impact. Techniques for managing the psychological impact include training, equipment, camaraderie, communication, preparation, education, support, and a growth mindset for the future. It was important for academic leaders to be present, communicate effectively, encourage and practice self-care, normalize grief and reactions, provide resources, and plan ahead.26
The COVID-19 pandemic demonstrated the importance of organized dentistry. Organizations such as the American Dental Association, American Dental Education Association, American Association of Dental Research, and many others served various important roles. In addition to state and federal governmental agencies, these organizations provided guidance on the safe practice of dentistry, served as advocates for the profession and patients. They sponsored multiple virtual conferences, and advisory documents provided a framework for dental practitioners.
Dental organizations served the important role of advocacy for dentistry's challenges during the COVID-19 pandemic. The coordination with government health departments served to demonstrate the importance of oral healthcare as an essential service. This allowed the safe reopening of dental practices. Organized dentistry advocated to both state and federal governments about a host of issues that aim to help rejuvenate dental practices and support dental providers during and after the pandemic. Organized dentistry was also intimately involved in advocating for federal small business loans, expanding dentists' role in telehealth reimbursement, expanding access to PPE, and vaccinations. Organized dentistry had a significant influence on policy decisions at a local, state, and national level.13
Prior to the pandemic, dental organizations commonly held annual or semi-annual meetings to bring the profession together. The pandemic resulted in the cancelling of multiple in-person meetings hosted by various dental organizations. This prompted dental organizations to shift their attention to utilize virtual conferences to disseminate information and maintain usual organizational operations.27 Online communities on social media and organizational message boards allowed communication and dissemination of critical information being shared rapidly and globally. Organized dentistry served a critical role in the distribution of information and advocacy during the COVID-19 pandemic.
The transmissibility of SARS-CoV-2 makes dental providers highly exposed to a risk of infection. The COVID-19 pandemic altered dentistry in the community, at academic dental institutions, and for representative organizations. Dentistry responded to safely deliver care for patients, including the vulnerable and underserved. As we look to the future, increased flexibility and preparedness for pandemics from an operational, educational, budgetary, organizational, and psychological perspective is necessary.28 The resilience and adaptability of the dental profession were keys to the success in the resumption of dental training and practice.
About the Authors
Neeraj Panchal, DDS, MD, MA
Assistant Professor and Section Chief of Oral and Maxillofacial Surgery, Philadelphia Veterans Affairs Medical Center, Penn Presbyterian Medical Center, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania
Mark Wolff, DMD, PhD
Morton Amsterdam Dean, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania
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