34 minute read
Global Impact of COVID-19 on Service Delivery and Vulnerable Populations’ Access to Dental Care
Francisco Ramos-Gomez, DDS, MS, MPH; Morenike Oluwatoyin Folayan, MBChD, MBA; Marcela Diaz-Betancourt, DDS, MIPH; Gyanendra Kumar, MDS; Thomas Gerhard Wolf, DDS, Dr med dent Priv-Doz; Margherita Fontana, DDS, PhD; and Guglielmo Campus, DDS, PhD
ABSTRACT COVID-19 is most commonly spread through aerosol droplets and contact with infected individuals and contaminated surfaces. The nature of how this virus is spread will affect the practice of dentistry for the foreseeable future. The aim of this paper is to provide an overview of the global impact of COVID-19 on dental professionals as well as highlight the barriers and challenges of global access to oral health care during the pandemic, especially among vulnerable populations.
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AUTHORS
Francisco RamosGomez, DDS, MS, MPH, is a professor in the section of pediatric dentistry and director at the UCLA Center for Children’s Oral Health at the University of California, Los Angeles, School of Dentistry.
Morenike Oluwatoyin Folayan, MBChD, MBA, is a professor of pediatric dentistry at the Obafemi Awolowo University in Ile-Ife, Nigeria.
Marcela DiazBetancourt, DDS, MIPH, is a scientific associate in the department of restorative, preventive and pediatric dentistry at the University of Bern School of Dental Medicine in Bern, Switzerland.
Gyanendra Kumar, MDS, is an associate professor of pediatric and preventive dentistry at the Maulana Azad Institute of Dental Sciences in New Delhi.
Thomas Gerhard Wolf, DDS, Dr med dent, Priv-Doz, is a senior physician in the department of periodontology and operative dentistry at the University Medical Center of the Johannes GutenbergUniversity Mainz in Mainz, Germany. He is also associate professor at the University of Bern School of Dental Medicine in Bern, Switzerland.
Margherita Fontana, DDS, PhD, is the Clifford Nelson endowed professor of dentistry in the department of cariology, restorative sciences and endodontics at the University of Michigan School of Dentistry.
Guglielmo Campus, DDS, PhD, is an associate professor in the department of surgery, microsurgery and medicine sciences at the University of Sassari School of Dentistry in Sassari, Italy. Conflict of Interest Disclosure for all authors: None reported.
In December 2019, a highly infectious respiratory disease started to spread in Wuhan, China, and escalating in the lapse of three months to a pandemic. [1] In January 2020, the World Health Organization (WHO) announced that this novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS CoV-2), was the pathogen causing the COVID-19 disease [1] and was a public health emergency of international concern. [2]
This paper provides an overview of the global perspective of COVID-19 as it relates to the following three oral healthrelated topics: the impact of COVID-19 on oral health care providers and dental practice; how COVID-19 affects access to oral health care services and unmet needs among vulnerable populations; and understanding the barriers and challenges to global access to oral health care during the pandemic by sharing perspectives from different regions of the world.
Impact of COVID-19 on Oral Health Care Providers and Dental Practice
The potential risk for COVID-19 infection is a major stress inducer for many oral health care workers, as they are considered high-risk health care providers. [3] The lack of a preventive vaccine and effective treatment further heightens this concern, thus placing a high psychological toll on them. [4]
During dental appointments, avoiding close contact and adhering to social distancing guidelines creates myriad issues for dental providers. Infectious agents can be transmitted between patients and oral health workers in the dental clinic environment through infected air droplets, saliva and instruments contaminated with secretions. [5] The close person-toperson contact during dental clinical care and the spatters and aerosols produced during routine dental treatments further increase the risk of transmission of pathogens from patients to dentists. This risk is heightened when managing asymptomatic carriers of disease pathogens or those in the postinfection “window period” during which antibodies cannot be detected. [6,7]
The long incubation period of seven to 24 days for COVID-19 and the risk of exposure to the pathogen through the respiratory system during face-to-face contact 8 and through the oral cavity [8,9] and gingiva fluid 10 during dental procedures are of great concern to dental care providers. [7] The use of instruments that create aerosol droplets generate cross-infection challenges when providing dental care. [1,11] Thus, developing and implementing rigorous and effective infection and management control protocols for dental practitioners and other oral health care providers is crucial, especially in nations with large numbers of COVID-19 cases. [9]
COVID-19 Clinical Oral Health Care Prevention Approach: The Hierarchy of Controls
In the midst of the COVID-19 pandemic, resources like the hierarchy of controls framework (FIGURE) can be especially helpful for dental providers as they navigate appropriate safety measures to adopt during clinical visits. Following the hierarchy of controls framework normally leads to the implementation of inherently safer systems with significantly reduced risk of illness or injury. [12,13] The hierarchy of controls framework outlines an inverse pyramid of five levels of protective measures in order of most to least effective as follows. [12] The five levels include: elimination and substitution (changes in equipment or procedures that reduce exposure to hazards); engineering controls (isolating employees from hazards connected to their work by taking measures to reduce exposures to such hazards); administrative controls (implementing changes in work policies or procedures in order to minimize exposure to hazards); and the use of personal protective equipment (face masks, face shields, gloves, goggles and respiratory protection as appropriate).
The Need for Minimally Invasive Dentistry and Teledentistry in Light of the COVID-19 Pandemic
The COVID-19 pandemic has highlighted the importance of using minimally invasive restorations and procedures within dentistry. The most recent recommendations published by the Centers for Disease Control and Prevention (CDC) urge dentists to avoid, when possible, procedures that might produce aerosols. [14] This includes avoiding the use of dental handpieces, air/water syringes and ultrasonic scalers that place dentists at a higher risk because the spray created by items such as handpieces, ultrasonic scalers and air-water syringes can contain particle droplets of water, saliva, microorganisms and other materials. [14,15] While surgical masks can be used to protect an individual’s mouth and nose from droplets, they cannot be relied upon to prevent wearers from inhaling infectious agents that exist in the air. [14]
In circumstances that do require aerosol-generative procedures, the CDC advises dentists to minimize aerosols by using four-handed dentistry, dental dams and high-volume evacuators (HVEs). [14] The standard HVE device used in dentistry has a large opening and is attached to an evacuation system that will remove a volume of air up to 100 cubic feet per minute. HVEs control the spray from aerosols and can reduce the risk of transmitting the virus. Studies have shown that HVEs can reduce 90% to 98% of aerosols regardless of the source. As there is no single solution that will provide complete protection, a combination of protective measures including PPE, preprocedural rinses, prepolishing, an advanced air filtration system and HVEs offers the most effective and practical method of reducing the overall risk of infection from viruses such as COVID-19. [16]
The emerging trend of teledentistry/ telehealth started before the COVID-19 pandemic, but the pandemic has put this option at the forefront as it serves as a means to avoid potential exposure to aerosolized infectious agents for those patients with nonemergent needs. Teledentistry allows for the exchange of clinical information and images over remote distances for consultation, diagnosis, treatment planning, dental care and education. [17,18] For example, dentists and other oral health care providers could conduct an initial oral health assessment via phone or computer. Based on the initial assessment, the provider can then rank appointment urgency remotely to arrange for in-person visits when needed.
COVID-19 and Access to Services and Unmet Needs of Vulnerable Populations
In response to the initial fear and concern about contracting COVID-19, large numbers of private and public clinics were closed and some were open only for emergency care. [3] Closures also came per recommendations from the CDC in an effort to preserve PPE for front-line health care workers. [14] The impact of this response is not only about the loss of revenue for the dental clinics and the dental workforce, but also the inability of individuals to access routine oral health care with significant implications for vulnerable populations.
Vulnerable and special needs populations, such as medically compromised patients, the elderly, young children and individuals with disabilities, are reliant upon routine health care to prevent deterioration of their overall health, including oral health. It is estimated that 15% of the world’s population experience some form of disability and 20% of the estimated global population experience significant disabilities. [19] Many persons with disabilities also have health comorbidities that compromise their health and increase their need for routine oral health care. [19] The inability to access routine dental health care will have a significant negative impact on the oral health and quality of life of these vulnerable populations. [19]
FIGURE. Hierarchy of controls framework. 12
Additionally, people with special health care needs and disabilities are at increased risk of contracting COVID-19 because of multiple factors such as poor access to information, increased risk of poverty, poor housing and sanitation and social and economic exclusion. [19,20]
Understanding and Addressing Oral Health Disparities in the Context of Macro- and Microsystem Levels as They Relate to COVID-19
Addressing oral health disparities in vulnerable and at-risk populations requires a multifaceted approach, which includes changes at both the macro- and microsystem levels. Macro-level systems operate on a large scale that can affect entire communities, states and countries.[21] Micro-level systems operate at the individual level. [21] COVID-19 can be considered an example of a macro-level systemic factor. It affects oral health equity and social justice on a global level and can lead to the continuation of privilege for some and discrimination for others based on characteristics such as economic status, gender, age and special needs status. [21]
For example, at the macro level, policies and governance systems during the COVID-19 pandemic severely impacted access to markets and food, as many countries instituted a lockdown or shelter-in-place policy to restrict movement as a way to contain the pandemic. The inability of individuals to obtain food, especially vulnerable populations that are greatly affected by food insecurities, can impact the maintenance of a healthy diet, which will have implications for the oral health of affected individuals in both the short and long term. [22] Scardina and Messina [23] clearly outline how poor diet affects dental organogenesis, maxilla growth and skull/facial development and increases the risk of oral diseases.
Mandatory shelter-in-place orders resulted in many health care institutions limiting services to emergency care in multiple countries. This has implications for a potential increase in health morbidities associated with oral health care. For example, when patients’ diabetes mellitus and kidney disease conditions deteriorate, the risk of periodontal diseases also increases. [24–26] Similarly, COVID-19 is associated with increased risk of developing diabetes mellitus [27] and kidney injury, [28] thereby being an indirect risk factor for oral diseases. COVID-19 has also been shown to be associated with poor oral health, including oral manifestations such as mucosal lesions [29] in the mouth, which is unique to the disease. [30,31]
At an individual (micro) level, childhood difficulty with speech, attention problems in school and negative social interactions and/or lack of social relationships that result from poor oral health can have a lifelong impact. [32] Addressing macro-level forces within a health equity and social justice framework can have a positive impact on microlevel systemic factors. This affects an individual’s overall health in various ways The inability of individuals to obtain food can impact the maintenance of a healthy diet, which will have implications for the oral health of affected individuals. that include creating a culture of oral health that promotes a comprehensive approach to total health and wellness as a continuum of medical/dental integration throughout the COVID-19 pandemic and making it possible to access culturally and linguistically sensitive providers through telehealth programs to reduce the burden of disease throughout the pandemic.
Understanding the Barriers and Challenges Related to Global Access and Oral Health Care During the Pandemic: Worldview Perspectives
THE WHO GLOBAL PERSPECTIVE ON COVID-19
Recently, the WHO published guidelines on the considerations for essential oral health services during the COVID-19 pandemic, [33] confirming the recommendations produced by the U.S. Occupational Safety and Health Administration (OSHA) that divided job tasks into four risk exposure levels for COVID-19, from low to very-high risk. These risk categories affect all dental health care personnel: dentists, dental hygienists and dental assistants. [34] Thousands of dentists from [35] low-, middleand high-income countries expressed their concerns about the impact of the COVID-19 pandemic on their practice in one of the largest global surveys in recent history. [35] The major concerns included risk of contagion, testing, transfer of dental care costs to patients due to increasing PPE expenses and how teledentistry will fit into the field of dentistry. [35]
The University California, Los Angeles (UCLA) School of Dentistry Section of Pediatric Dentistry Department designed and disseminated a survey in conjunction with the WHO to assess the impact COVID-19 had on dentistry at a global level. As part of this survey, UCLA included several questions to assess the financial impact of the pandemic as well as quality of life of U.S. dentists who completed the survey. Dentists reported experiencing a significant amount of financial hardship. They reported a significant reduction in the hours spent at the office, in patient visits and procedures being performed. Regarding the qualityof-life questions, responses indicated that a majority of dentists were not having trouble concentrating, were not feeling sadness or depression and were not having difficulty completing routine activities.
ACCESS TO DENTAL CARE AT THE GLOBAL LEVEL DURING COVID-19: A CIRCUITOUS ROUTE
According to the WHO Department of Noncommunicable Diseases in Geneva, urgent dental care has been the second most disrupted service in 122 countries during the pandemic. [36] This department consists of the WHO Oral Health Program along with cardiovascular diseases, chronic respiratory diseases, diabetes, cancers and mental health conditions. Despite the influence of oral infections on diabetes and cardiovascular diseases [36] and the recognized need to ensure continuity of care for pain and orofacial infections and trauma, even urgent dental care has been curtailed during the pandemic.
Several reports and recommendations on workflows, guidelines and hygiene protocols were issued for dentists all over the world. [37,38] Webinars, virtual conferences and online lectures complemented the spectrum of measures taken in dental facilities, universities and dental hospitals to ensure timely and appropriate information management and support. However, there is still a lack of published data on nosocomial infections associated with the movement of patients seeking treatment for dental pain during the pandemic. Additionally, the evaluation of broader aspects of service provision, such as the establishment of regional urgency shifts and dental services, triage procedures, teleconsultation scope and standards, is still in its infancy.
Restriction of interactions between patients and dental practitioners in offices or hospitals during lockdown is only one of the multiple aspects affecting access to oral care at the global level. Unavailability of qualified oral health professionals, distance to services, poverty, out-ofpocket expenditures, [39] reimbursement fees, [40] lack of universal health coverage, expensive dental material supplies and underfunded health systems continue to be barriers to care. While these barriers to care are not new, they have been exacerbated by the pandemic.
In the postpandemic recovery context, there will be a need to reach out to communities to assess their needs (especially in underserved and vulnerable populations), gather relevant data and evaluate findings to facilitate the development of projects with immediate benefit for preventive/ therapeutic intervention and to establish policy dialogue with decision-makers at the country level.
ASIAN PERSPECTIVE: INDIA
The first case of COVID-19 reported in India was on Jan. 30, 2020. The number of active cases continues to increase (approximately 12.4 million cases at the time of this writing), and as a result, the dental community faces a challenge to define the “new normal” of dentistry while prioritizing quality dental care for patients. For the first time ever in India, the government has become involved in establishing guidelines for dental practices. While dentists have continued to provide treatment following the guidelines established by the government, these guidelines are subject to change and have the potential of becoming more stringent as the number of COVID-19 cases increases.
The fear of contracting the disease in dental clinics has created a change in the psyche of both dentists and patients in India. Initially, more than 90% of dentists closed their clinics and struggled to determine the best way to operate and sustain their practices under the changed conditions. Many dentists suspended all emergency treatments for their patients, and some dentists have reported increased levels of depression. [2] Patients are no longer being treated on a “first-come, first-served” basis; instead, they are treated based on the emergency level of the procedure. The concept of teledentistry has come to the forefront, and it has become a mandate to call each patient beforehand to ascertain the level of need for the visit. [41] Additionally, inquiring about the personal, travel and medical history of patients has become mandated among dental practices.
At the structural level, precautionary measures at dental clinics in India focus on the design of the office, the need for a well-ventilated operatory with appropriate air flow and the use of negative-pressure equipment in addition to disinfection measures in order to maintain hygiene and sanitation after every patient. Before COVID-19, gloves and head caps were the only protective measures for dentists, but now PPE kits are mandatory while examining or treating patients. [42] Patients have also been made aware of the hygiene measures implemented in dental clinics and the need for efficient sterilization.
Currently, zones in India are categorized based upon the number of active cases: red (greatest number of cases), orange (mid-level number of cases) and green (fewest number of cases). Dentists have to modify their treatment modalities depending upon the zone to which the patient belongs; as such, where the clinic is situated will greatly impact dental practices. Since initial closures, dentists have been advised to conduct only emergency dental procedures in red zones, whereas full dental consultation is allowed in orange and green zones under all precautionary measures.
AFRICAN PERSPECTIVE: NIGERIA
The first case of COVID-19 in Nigeria was reported on Feb. 27, 2020, traced to an international traveler from Italy. Since then, the number of COVID-19 cases in Nigeria and the continent of Africa began to increase exponentially. As of Aug. 1, 2020, there were 926,917 COVID-19 cases in Africa. This constituted 5.3% of the 17,579,197 cases of COVID-19 reported globally at that time. [43] There were also 19,645 deaths from COVID-19. Nigeria had the third highest number of cases in African countries (43,151) after South Africa (493,183) and Egypt (94,078) and the fourth highest number of deaths (879) after South Africa (8,005), Egypt (4,805) and Algeria (1,210). [43]
The Nigerian government responded to the pandemic by establishing a presidential task force that developed a national strategy for the COVID-19 response. It shut down schools, closed state borders and imposed lockdowns. The economic impact has been huge, with a drastic increase in food insecurity due to the pandemic’s disruption of farming, food supply chains and trade. [44] The Nigerian workforce, 1.15 million people, 83.2% of whom operate in the informal sector, could not be effectively reached with cash and food distribution, especially the most vulnerable households. [44]
The decade-long conflicts in some parts of the country have increased the risk of COVID-19 for over 7 million Nigerians in conflict areas, approximately 2 million people in internally displaced persons camps and nearly 475,000 people in highly congested camps. These areas will be most affected by the pandemic, especially because they currently have a high prevalence of comorbidities with other diseases such as endemic cholera, malaria, Lassa fever, measles and chronic malnutrition. The country has also had to deal with distrust and disbelief about the pandemic from large sections of the community, thus limiting individuals’ use of face masks in public and social distancing. [44]
Public hospitals were initially open to emergency cases only to enable hospitals to focus on managing patients with COVID-19 infection and reducing the risk of hospital transmission of infection to nonCOVID-19 patients. However, on April 18, 2020, the coordinator of the presidential task force issued a directive to reach out to the relevant professional associations to draft operational guidelines for resuming nonemergency patient care. The Division of Dentistry also received this directive, and the Nigerian Dental Association was charged with the responsibility of developing guidelines applicable to both public and private dental practice sectors. The guidelines stipulated the use of advice, analgesics and antimicrobials for the management of nonemergency dental care, identified what cases are considered dental emergencies and should be handled during the pandemic, how staff and patients are to be evaluated before entering the main clinic, procedural practices for patients, posttherapy instructions, waste management and management of patients with COVID-19 symptoms. Screening questions now include questions about international travel history and travel from high-epidemic areas as part of the patient’s medical history. The use of long-sleeved scrubs, waterproof aprons, disposable gloves and face shields are part of the mandatory PPE to be worn while conducting nonaerosolgenerating procedures. When conducting aerosol-generating procedures, respirators are expected to be worn in addition to wearing full surgical gowns, waterproof aprons, full-face shields and covered shoes.
While public and private clinics that shut down during the early days of the COVID-19 pandemic are gradually opening to provide services to the public, precautionary measures have been instituted. Private dental clinics are not allowed to manage patients with COVID-19 symptoms. In the public setting, symptomatic and asymptomatic patients with COVID-19 infections are expected to be referred to designated COVID-19 management centers for care in any of the 37 states in Nigeria.
Finally, the populations who have limited access to oral health care and who had traditionally been reached through outreach and sponsored programs [45] will be at a huge loss during this period where outreach has been suspended in order to limit close social contact. In effect, COVID-19 may have further widened the disparities in access to oral health care among these vulnerable populations in Nigeria, thereby worsening oral health inequity in the country.
EUROPEAN PERSPECTIVE: ITALY, GERMANY AND SWITZERLAND
Italian perspective. Italy saw a rapid increase of COVID-19 at the beginning of the pandemic. As of May 2020, Italy was still among the European countries with the highest number of COVID-19 cases. The majority of cases were concentrated in the northern part of the country (Lombardy). [37] Health care workers were greatly impacted by the pandemic. As of May 12, 2020, the official number of COVID-19-infected health care workers was 21,981. A survey carried out during the peak of the pandemic provided some insight into the impact of COVID-19 on dental professionals, and a high percentage of the dentists reported symptoms attributable to the infection.
GERMAN PERSPECTIVE. According to the Ministry of Health in Bavaria in southern Germany, the first confirmed case of COVID-19 in Germany was on Jan. 27, 2020. Since then, new cases have been reported continuously and several patients have been hospitalized.
On Feb. 28, 2020, the Robert KochInstitute in Berlin assessed the risk of COVID-19 for Germany and initially classified it as “low to moderate” for the population. [46] This was revised on March 17, 2020, to reclassify COVID-19 as a “high-level risk” for the population in Germany, and for at-risk groups the risk level was “very high.” [46] This was taken as an opportunity for the Bundestag to identify an epidemic situation of national importance, and on March 27, 2020, it passed a law entitled “Law to protect the population in the event of an epidemic situation of national importance.” [47] This allowed orders to be issued at the federal level in the federal health system without the consent of the Federal Council. Since then, a worldwide travel warning was issued, nonessential travel to the EU was restricted, numerous businesses were closed and an entry ban for thirdcountry nationals was implemented.
Regarding dental services during the lockdown, many regions in Germany restricted dental care to emergency care only. Therefore, elective procedures were to be postponed and risk groups were to be treated with special protective measures. [48] Nevertheless, dentists with a health insurance fund license (legally insured, state-owned) were obligated to treat patients.
THE SWISS PERSPECTIVE. In early February 2020, the Swiss canton of Ticino in the south of Switzerland, bordering on northern Italy and the Lombardy region not far from Milan, identified two COVID-19-positive individuals. The increase was so rapid that on Feb. 28, 2020, the Swiss Federal Council assessed the situation as a “special situation” under the Epidemics Act and adopted the Ordinance on Measures to Combat Coronavirus (COVID-19). A campaign by the Swiss Federal Office of Public Health was launched on March 1, 2020, with hygiene recommendations for protection against COVID-19. [49]
The Swiss Dental Association (SSO) developed a protection clause for dental surgeries during the period of the emergency legislation passed by the Federal Office on March 16, 2020. [50] Furthermore, also on March 16, 2020, the Swiss Federal Council defined the “extraordinary situation” due to the highest danger level with measures to protect the population in accordance with the Epidemics Act. As a result, all shops, restaurants, bars as well as entertainment and leisure facilities, with the exception of grocery stores and health care facilities, were closed until April 19, 2020. [49] The “extraordinary situation” was later extended until April 26, 2020. However, according to the COVID-19 Ordinance, practices and health care facilities must have a protection clause that is appropriate to the situation and operation. [49]
The “Smart Restart” initiative by the Swiss Dental Association (SSO) allowed for individual implementation of protective measures such as PPE and has made it possible to reopen dental practices for patient care since April 27, 2020, largely without restrictions. [51]
UNITED STATES PERSPECTIVE
On March 13, 2020, the U.S. government responded to the COVID-19 pandemic by declaring a national emergency. Following this, the CDC and the American Dental Association (ADA) recommended that dentists nationwide defer elective dental treatment and focus on emergency care. This was further reinforced by OSHA’s recommendation that dental treatment during the COVID-19 pandemic use a combination of standard contact precautions and droplet precautions, including eye protection (e.g., goggles or face shields) to protect dental professionals performing patient care that does not involve aerosol-generating procedures on individuals not suspected or confirmed to be COVID-19 positive. When performing aerosol-generating procedures, additional airborne precautions were added to protect dental professionals. While the lack of national precautionary guidance and severe PPE shortages led to the closure of many dental offices early in the pandemic, by May 2020, the ADA and several states in the U.S. issued guidance for reopening dental practices.
In March 2020, the ADA Health Policy Institute initiated a nationwide biweekly poll on the economic conditions during the pandemic to quantify the magnitude of the pandemic’s impact on dental practices over time. The survey results showed that by July 27, 2020, nearly all offices were open; however, patient volume was estimated to be 73% of pre-COVID-19 levels. Dental offices continued to experience N95 respirator and PPE shortages and higher expenses for instituting PPE. An encouraging finding was that data from consumer polling indicated 80% of adults were very comfortable visiting the dentist now, reflecting a high level of confidence in the infection control measures being undertaken.
In the U.S., COVID-19 has particularly affected certain racial and ethnic minority groups. Data show that African Americans continue to experience the highest overall COVID-19 mortality rates — about 2.3 times as high as the rate for whites and Asians. [45] According to the CDC, inequities in the social determinants of health, such as living conditions, poverty, health care access and underlying medical conditions affecting these groups, increase their risks for infection and death. [52] African Americans and Latinos are disproportionately represented in certain occupational settings that put them at increased risk of contracting the virus due to several factors, such as close contact with others, inability to work from home, a lack of sick days, crowded housing and the use of public transportation.
CALIFORNIA PERSPECTIVE
In California, statewide shelterin-place and “safer-at-home” orders began on March 16, 2020, and remained in place in most cities until mid-June when they were loosened. Similar to other countries, all nonemergent dental services were required to shut down. As the provision of nonemergent dental services slowly resumes in California, dental clinics and dental health care personnel are instructed to follow the recommendations and guidelines set forth by the CDC and the California Department of Public Health (CDPH) and Cal/OSHA guidance for resuming deferred and preventive dental care. In addition to these guidelines, the California Dental Association (CDA) developed practice guidance that worked in conjunction with the guidelines set forth by the CDPH. [53] These guidelines stipulate that dental clinics should balance the need to provide necessary services while minimizing risk to patients and staff. Before providing any care, it is important to ensure that appropriate PPE and sanitation supplies are available to support patient volume and that updated engineering controls, work practice protocols and infection control measures are in place.
Discussion
The COVID-19 pandemic has had a major impact on dental professionals and the delivery of dental care worldwide. Not only have dental practitioners been required to implement rigorous and effective infection and management control protocols in the dental setting for both providers and patients, they will also have to come up with solutions to ensure the most vulnerable populations are able to access needed dental care. The pandemic has also impacted the mental and social psyche of both dental practitioners and patients. This paper presents some of the challenges currently being faced by dental professionals worldwide and discusses potential solutions to these challenges. The following is a summary of key findings.
Early on in the pandemic, dental care was restricted to emergency cases in much of the world. However, as nonemergent dental care has slowly resumed, several reports and recommendations on workflows, guidelines and hygiene protocols were issued for dentists worldwide. [37,38] Mandates have included the use of PPE for providers (e.g., face masks, face shields, goggles, gloves and respiratory protection) and highlighted the importance of using minimally invasive restorations and procedures to reduce the spread of infection. Structural changes have also been instituted in many clinic environments to reduce the risk of transmission (e.g., improving office ventilation with appropriate air flow, use of negativepressure equipment and disinfection measures to maintain hygiene and sanitation after every patient.)
The large number of private and public clinics that were closed early in the pandemic resulted in the inability of individuals to access routine oral health care, which has significant implications for vulnerable and special needs populations who are reliant upon routine care to prevent deterioration of their overall health. To address this concern, practitioners have turned to the concept of teledentistry or “virtual dental check-ups” to help reduce the need for in-person visits and increase access to care for vulnerable and underserved populations. However, reaching the very poor or individuals who don’t have access to technology is still a gap that needs to be addressed.
Finally, the fear of contracting COVID-19 in dental clinics has created a change in the psyche of both dentists and patients. Many dental professionals have still not determined the best way to operate and sustain their practice under the changed conditions, and some dentists have reported increased levels of depression. [2] Additionally, patients in some countries continue to report hesitancy regarding going to the dentists for fear of contracting COVID-19. [3] Teledentistry comes to the forefront on how to relieve some of these stressors for both providers and patients, but more research is needed to better understand the psychosocial impact of COVID-19 on dental providers and how best to address this problem.
Conclusion
The COVID-19 pandemic has created many challenges for the field of dentistry and oral health care, many of which will have lasting impacts, especially economically and financially. The oral health care system was already dealing with issues of access to care and medical/dental integration as a way of maintaining continuity of care as well as addressing oral health disparities. All of these complex issues have been exacerbated by the COVID-19 pandemic. As the pandemic draws on, and continues, it will be important for dental practitioners and other oral health care providers to continue to assess issues that arise in the field and keep finding ways and opportunities to be creative and to provide care to the most at-risk and vulnerable populations worldwide.
ACKNOWLEDGMENTS We express our sincere gratitude to all of our authors, additional contributor Jayanth Kumar, DDS, MPH, and our research assistants Helen Lindau and Janni Nadjat-Haiem who are dedicated to advancing dentistry and oral health practices while addressing the difficulties that the COVID-19 pandemic have presented for the field.
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THE CORRESPONDING AUTHOR, Francisco Ramos-Gomez, DDS, MS, MPH, can be reached at frg@dentistry.ucla.edu.
