Perspectives from the Pandemic
The first case of Coronavirus Disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), was identified in the United States on January 21, 2020.1 Since then, disruption caused by the pandemic has impacted lives, disrupted economies, and transformed healthcare delivery. As of March 2021, well over 120 million cases have been identified worldwide and the death toll attributed to COVID-19 infections has reached nearly 3 million individuals globally.2 Given these staggering numbers, it is understandable that the dental field has experienced changes and potential paradigm shifts that may persist into our "next" normal as the pandemic subsides.
During the early part of the pandemic, most dental offices delivered care limited to urgent and emergent services,3 but with increased availability of personal protective equipment (PPE) and reopening guidance from public health and professional organizations,4-6 expansion of dental services with additional precautions and screening in place became more widespread.3-6 The most recent data from the American Dental Association's Health Policy Institute suggest that dental patient volume has increased to above 80% of pre-pandemic levels and has plateaued.3 Based upon patient surveys, these numbers will likely remain steady until there is widespread vaccination distribution and further decrease in community spread.3
Given the upheaval that dentistry has experienced over the last year, it is important to assess what we have learned from the pandemic and how those lessons may be applied to our future practice.
Dental Healthcare Workers are Essential Health-care Workers. Early in the pandemic, dental healthcare providers (DCPs) were identified as a key group of highly trained healthcare workers who could screen patients to assess risk, administer COVID-19 testing, and provide additional supportive care for front-line workers.7,8 Emergency authorizations in hard-hit areas, such as New York and Washington, requested that DCPs volunteer to aid an overwhelmed healthcare infrastructure.8,9 Further, as vaccine development produced promising vaccine candidates, three of which have received emergency use authorization (EUA) as of this writing, DCPs came into focus as individuals who could potentially deliver some of the hundreds of millions of doses needed to achieve herd immunity in the US.10 Several states have approved dentists and/or dental hygienists to deliver vaccine doses.11 Furthermore, the US Centers for Disease Control and Prevention (CDC) designated dental healthcare workers, including dentists, dental hygienists, and dental assistants, in the highest priority tier to receive vaccinations, based upon the essential nature of dental healthcare and its impact on public health.12
Use of Enhanced Infection Control Practices Served to Keep COVID-19 Transmission Low Among Dental Healthcare Professionals.Initial assessment of occupational risks placed DCPs in an extremely high risk category based upon their close proximity with patients, their exposure to aerosols during the delivery of patient care, and the potential for asymptomatic and presymptomatic patients to shed virus and cause infection.13 Assessment of the incidence of COVID-19 infection in both dentists and dental hygienists demonstrated that, despite these initial concerns, DCPs had high rates of compliance with enhanced infection control and prevention protocols and significantly lower incidence of COVID-19 infection than those seen in other healthcare providers and/or within the communities.14,15 This news is comforting to DCPs and patients alike, but it is not necessarily surprising given the near-universal adoption of infection control practices in dental offices, even prior to the pandemic.14,15 These data continue to be monitored but they are certainly reassuring that the dental office is a safe environment in which to work and receive care.
Oral Inflammation is Related to Overall Health. One of the puzzling features of COVID-19 is the spectrum of clinical presentations seen in patients infected with the SARS-CoV-2 virus.16,17 Initial data indicated that many patients who suffered from serious COVID-19 symptoms (often resulting in hospitalization and/or death) had other comorbidities, particularly those that were related to chronic inflammatory conditions and/or immunocompromised status.18 Given these findings, it was initially hypothesized that oral chronic inflammatory conditions, particularly periodontitis, could contribute to a hyperinflammatory state and worsen COVID-19 symptoms, particularly those associated with severe disease and a cytokine storm.19 A recent publication found that in patients hospitalized for COVID-19, periodontitis was a significant risk factor for more severe disease and increased the risk of death by nearly nine times.20 The pandemic has highlighted the importance of overall wellness for many people, and this emerging evidence suggests that the identification of periodontal disease along with treatment and maintenance may be critical to reducing risks of high-consequence infectious diseases for patients.
A year ago, it would have been difficult to predict the journey that all of us have been on, but it has also shown us how resilient dentistry is as a profession and how critical the dental care we deliver is to patients and our communities.
1. A timeline of COVID-19 developments in 2020. American Journal of Managed Care. January 1, 2021. https://www.ajmc.com/view/a-timeline-of-covid19-developments-in-2020. Accessed March 5, 2021.
2. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Coronavirus Resource Center. Johns Hopkins University & Medicine. https://coronavirus.jhu.edu/map.html. Accessed March 5, 2021.
3. Health Policy Institute. COVID-19 Economic Impact on Dental Practices. Week of February 15 Results. American Dental Association. https://surveys.ada.org/reports/RC/public/YWRhc3VydmV5cy02MDJiZTU1N2M1MDZhNDAwMTFkNzgwMmUtVVJfM3BaeGhzWm12TnNMdjB4. Accessed March 5, 2021.
4. Summary of CDC COVID-19 Guidance for Dental Services. Centers for Disease Control and Prevention. December 1, 2020. https://www.cdc.gov/oralhealth/infectioncontrol/statement-COVID.html. Accessed March 5, 2021.
5. American Dental Association's Advisory Task Force on Dental Practice Recovery. Return to Work Interim Guidance Toolkit. American Dental Association. https://pages.ada.org/return-to-work-toolkit-american-dental-association. Accessed March 5, 2021.
6. ADHA Interim Guidance on Returning to Work. American Dental Hygienists' Association. August 5, 2020. https://www.adha.org/resources-docs/ADHA_TaskForceReport.pdf. Accessed March 5, 2021.
7. Psoter WJ, Meyerowitz C. Dentists as a surge workforce resource. J Am Dent Assoc. 2021;152(2):89-91.
8. New York City Medical Reserve Corps. City of New York Web site. https://www1.nyc.gov/site/doh/providers/emergency-prep/nyc-medical-reserve-corps.page. Accessed March 5, 2021.
9. Neumeister L, Villeneuve M. Call for virus volunteers yields army of healthcare workers. ABCNews. April 1, 2020. https://abcnews.go.com/US/wireStory/call-virus-volunteers-yields-army-health-care-workers-69920370. Accessed March 5, 2021.
10. Burger D. Dentists administering vaccines gaining acceptance in states. ADANews. February 3, 2021. https://www.ada.org/en/publications/ada-news/2021-archive/february/dentists-administering-vaccines-gaining-acceptance-in-states. Accessed March 5, 2021.
11. Mascarenhas L. Dentists, students called in to help deliver coronavirus vaccines. CNN. January 8, 2021. https://www.cnn.com/2021/01/08/health/non-traditional-covid-vaccinators/index.html. Accessed March 5, 2021.
12. The Importance of COVID-19 Vaccination for Healthcare Personnel. Centers for Disease Control and Prevention. December 28, 2020. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/hcp.html. Accessed March 5, 2021.
13. Langlois S. Here's a look at who is most at risk of contracting COVID-19 and how much they earn for taking that risk. Market Watch. April 16, 2020. https://www.marketwatch.com/story/heres-a-look-at-who-is-most-at-risk-of-contracting-covid-19-and-how-much-they-earn-for-taking-that-risk-2020-04-16. Accessed March 5, 2021.
14. Estrich CG, Gurelian JR, Battrell A, et al. COVID-19 prevalence and related practices among dental hygienists in the United States. J Dent Hyg.2021;95(1):6-16.
15. Estrich CG, Mikkelsen M, Morrissey R, et al. Estimating COVID-19 prevalence and infection control practices among US dentists. J Am Dent Assoc.2020;151(11):815-824.
16. Khan M, Khan H, Kham S, Nawaz M. Epidemiological and clinical characteristics of coronavirus disease (COVID-19) cases at a screening clinic during the early outbreak period: a single-centre study. J Med Microbiol.2020;69(8):1114-1123.
17. Hu B, Guo H, Zhou P, Shi Z-L. Characteristics of SARS-CoV-2 and COVID-19. Nat Rev Microbiol. 2021;19(3):141-154.
18. People with Certain Medical Conditions. Centers for Disease Control and Prevention. February 22, 2021. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html. Accessed March 5, 2021.
19. Pitones-Rubio V, Chávez-Cortez EG, Hurtado-Camarena A, et al. Is periodontal disease a risk factor for severe COVID-19 illness? Med Hypotheses. 2020;144:109969.
20. Marouf N, Cai W, Said KN, et al. Association between periodontitis and severity of COVID-19 infection: A case-control study [published online ahead of print February 2021]. J Clin Periodontol. doi: 10.1111/jcpe.13435.