CDA Journal - February 2022: Living and Practicing With COVID-19 by California Dental Association

Journa C A L I F O R N I A

D E N TA L

February 2022 Collective Strength Infection Control Impact of COVID-19 Oral Health Implications

A S S O C I AT I O N

Living and Practicing With COVID-19 n

Nº 2

F E B R U A R Y 2022

Vol 50

Natasha A. Lee, DDS

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Feb. 2022

C D A J O U R N A L , V O L 5 0 , Nº 2

d e pa r t m e n t s

75 Associate Editor/The Rise of Podcasts 77 Letter to the Editor 79 Impressions 125 RM Matters/The Employee Manual: An Important Tool for Communicating Employment Conditions and Expectations

131 Regulatory Compliance/Q&A: Dental Scope of Practice 133 Tech Trends

f e at u r e s

83 Living and Practicing With COVID-19 An introduction to the issue. Natasha A. Lee, DDS

87 Dentistry’s Collective Strength During Unprecedented Times This commentary provides an assessment of organized dentistry’s response to the COVID-19 pandemic in California. Richard J. Nagy, DDS C.E. Credit

Safe Dental Care During the COVID-19 Pandemic This article discusses reasonable infection control practices to prevent the spread of COVID-19 in dental patient care. Eve Cuny, MS

103

Impact of COVID-19 on Dentistry This article discusses the many ways the dental profession was and in some ways still is affected by the COVID-19 pandemic. Anders Bjork, MBA

119

COVID-19 and Oral Health Care: Implications for Dental Practices

This article covers the various health and procedural information dental practitioners must use to update their practices regularly. Jayanth Kumar, DDS, MPH

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Journa C A L I F O R N I A

published by the California Dental Association 1201 K St., 14th Floor Sacramento, CA 95814 800.232.7645 cda.org

CDA Officers Ariane R. Terlet, DDS President president@cda.org John L. Blake, DDS President-Elect presidentelect@cda.org

D E N TA L

Management Peter A. DuBois Executive Director Carrie E. Gordon Chief Strategy Officer Alicia Malaby Communications Director

Editorial Kerry K. Carney, DDS, CDE Editor-in-Chief Kerry.Carney@cda.org Ruchi K. Sahota, DDS, CDE Associate Editor

Carliza Marcos, DDS Vice President vicepresident@cda.org

Marisa K. Watanabe, DDS, MS Associate Editor

Max Martinez, DDS Secretary secretary@cda.org

Gayle Mathe, RDH Senior Editor

Steven J. Kend, DDS Treasurer treasurer@cda.org Debra S. Finney, MS, DDS Speaker of the House speaker@cda.org Judee Tippett-Whyte, DDS Immediate Past President pastpresident@cda.org

Volume 50 Number 2 February 2022

A S S O C I AT I O N

Jack F. Conley, DDS Editor Emeritus

Permission and Reprints

Journal of the California Dental Association Editorial Board

Robert E. Horseman, DDS Humorist Emeritus

Andrea LaMattina, CDE Publications Manager Andrea.LaMattina@cda.org 916.554.5950

Charles N. Bertolami, DDS, DMedSc, Herman Robert Fox dean, NYU College of Dentistry, New York

Production Shelly Peppel Senior Visual Designer

Manuscript Submissions

Upcoming Topics March/General Topics

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April/Pregnancy

Letters to the Editor

May/Dental Benefits Policy

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Sue Gardner Advertising Sales Sue.Gardner@cda.org 916.554.4952

Natasha A. Lee, DDS Guest Editor Andrea LaMattina, CDE Publications Manager Kristi Parker Johnson Communications Manager Blake Ellington Tech Trends Editor

The Journal of the California Dental Association (ISSN 1942-4396) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. The California Dental Association holds the copyright for all articles and artwork published herein.

Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental Medicine, Pomona, Calif. Mina Habibian, DMD, MSc, PhD, associate professor of clinical dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles Robert Handysides, DDS, dean and associate professor, department of endodontics, Loma Linda University School of Dentistry, Loma Linda, Calif. Bradley Henson, DDS, PhD , associate dean for research and biomedical sciences and associate professor, Western University of Health Sciences College of Dental Medicine, Pomona, Calif. Paul Krebsbach, DDS, PhD, dean and professor, section of periodontics, University of California, Los Angeles, School of Dentistry Jayanth Kumar, DDS, MPH, state dental director, Sacramento, Calif. Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral health education, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Nader A. Nadershahi, DDS, MBA, EdD, dean, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry Michael Reddy, DMD, DMSc, dean, University of California, San Francisco, School of Dentistry

The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor do advertisements constitute endorsement or approval of advertised products or services.

Avishai Sadan, DMD, dean, Herman Ostrow School of Dentistry of USC, Los Angeles

Brian J. Swann, DDS, MPH, chief, oral health services, Cambridge Health Alliance; assistant professor, oral health policy and epidemiology, Harvard School of Dental Medicine, Boston

Visit cda.org/journal for the Journal of the California Dental Association’s policies and procedures, author instructions and aims and scope statement.

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Harold Slavkin, DDS, dean and professor emeritus, division of biomedical sciences, Center for Craniofacial Molecular Biology, Herman Ostrow School of Dentistry of USC, Los Angeles

Richard W. Valachovic, DMD, MPH, president emeritus, American Dental Education Association, Washington, D.C.

Assoc. Editor

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The Rise of Podcasts Ruchi K. Sahota, DDS, CDE

e listened to news radio on the way to school every day. Traffic and weather on the eight-minute marks. Sports on the 15s and 45s. Stock market updates were sprinkled in with local and national news. My family, composed of immigrants raising children in the ’80s and ’90s, mainly played Indian music in the house — perhaps this was in an effort to maintain exposure to culture and the Indian roots. Needless to say, my house did not know what the Billboard music chart’s top 50 list included. I learned about Van Halen on a trip to Yosemite with my friend’s family. The latest country music or hip-hop music played as my fifth through eighth grade basketball teams ran onto the court. I came to appreciate Britney Spears in high school when I got my own car — and control over the radio station. The primary building blocks that my mother laid down with the news radio are deep in my consciousness. News radio provided material that felt focused and personalized. Traffic news was necessary to determine what route to take. Weather news was necessary to determine what to wear. Sports news was necessary to fuel the excitement for upcoming games. Over the years, the newscasters and their voices were not just familiar but felt like family. The jingles of each of the commercials were embedded in our cerebrums. During the months of shelter-in-place in the pandemic, listening to the news became less and less desirable. But there was still a desire for that information stimulation. It started with a podcast that featured analysis on a favorite reality show; it started with an opportunity to escape.

125 million people will likely listen to a podcast each month by next year. This quantifies about a 25% increase since before the pandemic.

Slowly one podcast led to a subscription to the series and then devouring many episodes. Many episodes led to a discovery of a world of topics, galaxies of contributors and a whole new universe of information stimulation. I was hooked. 125 million people will likely listen to a podcast each month by next year. This quantifies about a 25% increase since before the pandemic.1 The popularity of podcasts has exploded. For some, podcasts provide knowledge. For others, podcasts provide distraction. And sometimes — podcasts provide balance in the contribution of education and entertainment. According to a podcast production company, “49% of monthly U.S. podcast listeners are aged between 12–34, 40% between 35 and 54 years old, and 22% are aged over 55. Monthly podcast listeners also tend to work a full-time job.” Listeners of all generations are seeking connections to these new voices. The podcast experience is unique. The host or roundtable of hosts unabashedly speak into the microphones to their audience. They tell their stories as if the episode was an audible diary entry. Connection comes easy. Honesty and full disclosure are expected. The knowledgebased podcasts provide interviews with Diane Sawyer-like questions and a journalistic approach. The interviews are

probing yet conversational — lending to not only the idea of an informal connection to the audience, but also an aim to allow for the comprehensive digestion of ideas and answers given. Listening, most often, takes place at home or in the car. These are personal and focused times and environments. These scenarios lend to the feeling of a personal relationship being forged between listener and podcaster. Important information is disseminated. Hard questions are asked. Editing of the podcasts allows for clear, hopefully succinct answers. Imagine if CDA had a podcast back in early 2020. Imagine if we could have had a one-on-one conversation with Dr. Jay Kumar, our state’s dental director, during the beginning of the pandemic. We could have probed him about information he had from the CDC. What if we listened to the information that we instead had to read repeatedly on a variety of webpages? Would an audible FAQ have been beneficial during that time? What protocols did the state want to pass down to CDA member-dentists about the role their practices could play during that time? What was being communicated to the individual counties from the state? What was being coordinated at that time? Where could CDA dentists go to acquire emergency personal protective equipment FEBRUARY 2 0 2 2

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ASSOC . EDITOR C D A J O U R N A L , V O L 5 0 , Nº 2

when none was available to them to treat patients? While Zoom meetings have become commonplace, learning from a conversation of information in the podcast fashion is becoming more and more popular. Forbes reports that “Podcast listeners not only spend time with podcasts — they also engage on social media.2 So the consumption of knowledge does not stop in hearing the information — it is often carried over and shared with others quickly. Engagement is swift. The large quantity of podcasts that exists provides endless options. It also allows a plethora of interests to be enthused — both personal and professional. The growth in this arena has been remarkable — especially through the pandemic. There is a potential alcove for anyone and everyone. Subject matters range from parenting to true crime. So, dental podcasts can easily be found among the millions of podcasts on platforms like Spotify and Apple’s iTunes. Dentistry has so much to cover. Again, imagine if CDA had a podcast? Multiple podcast episodes could cover advocacy efforts. What legislative bills are in the Capitol in Sacramento that could impact small businesses like ours? What public oral health initiatives are CDA staff discussing at the Capitol? Multiple podcast episodes could include employment issues members are facing. How do we recruit new staff? How do we retain our staff? What human resources laws must we ensure we are maintaining in our offices? Multiple podcast episodes could include practice management. What kind of leadership role do memberdentists play in a dental office team? What percentage of our practice expense should go to overhead? How do we maintain our patient population? Multiple podcast episodes could include risk management. What are the issues that TDIC encounters in most of its insureds’ malpractice claims? 76

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What verbiage is important when we complete informed consent — verbal and written? Multiple podcast episodes could shine a light on well-being. What have been the experiences of our colleagues who encountered mental health challenges? What daily routines may help member-dentists to enhance their wellbeing? What are common trials dentists face in their daily lives? The opportunity for the information stimulation is vast. Someone said, “In a world of algorithms, hashtags and followers, know the true importance of human

of routine and security. It honored knowledge and the dissemination of that knowledge paramount. News radio content was predictable yet also potentially spur-of-the-moment. Podcasts are the same. However, podcasts provide an opportunity of more friendly, intimate connection as well. Sometimes the most beneficial relationships are the ones we do not expect. Have you found a love for podcasts? Write us and tell us about the voices that have you subscribing, learning and relishing in it all. n RE F E RE N C E S 1. Maiorca D. Why Podcasts Are Growing in Popularity. 2. Kaufer K. Who Listens To Podcasts (And How Can You Reach Them).

Focused, tailored and empathetic voices speak not just to deliver information, but to also connect.

connection.” The most appealing aspect of podcasts is the special relationship between listener and podcaster. Focused, tailored and empathetic voices speak not just to deliver information, but to also connect. The popularity of podcasts arose from the dust of the pandemic. While we could not attend large conferences or physically meet with our study clubs or dental societies, we could turn on a podcasting platform and hear someone speak to us. We could find a passion for a new voice. The new voice was a new friend or colleague. We could binge their episodes. The sense of congeniality would grow. We could share this excitement with our friends on social media. The sense of familiarity and connection would multiply. So many years ago, the news radio on the way to school provided a sense

Ruchi K. Sahota, DDS, CDE, practices family dentistry in Fremont, Calif., and serves on the CDA Board of Trustees. She is also a certified dental editor, a consumer advisor for the American Dental Association, past president of the Southern Alameda County Dental Society and a fellow of the American College of Dentists, International College of Dentists and the Pierre Fauchard Academy.

Letter

C D A J O U R N A L , V O L 5 0 , Nº 2

Dental Clearance Before BMT A knowledge gap exists among dental practitioners when treating patients in need of dental clearance before bone marrow transplantation (BMT). With no standard guidelines, dentists may have to consider certain factors before providing dental clearance. Patients’ medical and dental history and a complete examination including periodontal health, caries risk assessment and obtaining radiographs with an assessment of overall oral hygiene is essential. The most important aspect of the dental clearance is to eliminate potential infections including carious and periodontally compromised teeth and soft tissue/bony infections before BMT. When planning dental procedures, caution needs to be exercised about the risk of bacteremia, the need for antibiotic prophylaxis, the patient’s health status and the timeline of procedures. Treatment is tailored according to the patient’s needs in consultation with the treating physician, with an emphasis on regular recall. Prompt communication of the patient’s dental status with the physician is crucial.

The Journal welcomes letters We reserve the right to edit all communications. Letters should discuss an item published in the Journal within the last two months or matters of general interest to our readership. Letters must be no more than 500 words and cite no more than five references. No illustrations will be accepted. Letters should be submitted at editorialmanager.com/jcaldentassoc. By sending the letter, the author certifies that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publication elsewhere, and the author acknowledges and agrees that the letter and all rights with regard to the letter become the property of CDA.

C H I TR A PRI YA EMPERUM AL , BDS , MS , and SI VAPPIRI YAI V ELUPPILL AI , DDS

University of California, San Francisco, School of Dentistry

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Impressions

C D A J O U R N A L , V O L 5 0 , Nº 2

Parallels in Human, Dog Oral Tumors Could Speed New Therapies

Immunohistochemical validation of MAPK pathway activation and EMT. The asterisks indicate neoplastic cells and the arrows indicate tumor margins. (Credit: Peralta S, et al. Licensed under Creative Commons CC BY-NC 4.0.)

Recent research comparing the genetic expression profiles of a nonlethal canine tumor and the rare, devastating human oral tumor it resembles has laid the groundwork for potential translational medicine down the road. While canine acanthomatous ameloblastoma (CAA) is common and nonlethal, it has a strong resemblance to an oral tumor in humans known as ameloblastoma (AM). As a boarded veterinary dentist and oral surgeon, Santiago Peralta, DVM, associate professor at the Cornell University College of Veterinary Medicine (CVM) and first author of the recent study in Scientific Reports, sees CAA in his clinic frequently. “This research was a good example of a full cycle of translational research,” Dr. Peralta said. “We took something we were dealing with in the clinical setting, studied it in the bench setting and are now hoping to use it to help veterinary patients and, potentially, humans.” The resemblance between CAA and AM had long been noted by scientists and clinicians, but no one had confirmed any molecular similarities. A previous study on AM tumors revealed the underlying mutations, piquing the interest of Dr. Peralta and his colleagues. “We wondered if we should look at these mutations and see if they precipitate the canine tumor,” Dr. Peralta said. They did just that, publishing a study in Veterinary and Comparative Oncology in 2019 that revealed that both AM and CAA shared mutations in a well-known signaling pathway known as the RAS-RAF-MAPK. In their most recent study, Dr. Peralta and his colleagues analyzed a large genomic dataset generated by the Cornell Transcriptional Regulation and Expression Facility to better understand the biological consequences of these mutations. While doing so, they compared the CAA tumors with another common canine tumor (oral squamous cell carcinoma) and healthy gum tissue. The team also used genomic data from human tissues to run comparisons, thanks to their collaboration with a human oral cancer expert at the University of Turku in Finland. Through analyzing these different tissues, Dr. Peralta and his team were able to see that the mutations they had identified in their earlier study were largely responsible for the tumors they were seeing. They also found that CAA and AM are very similar at a molecular level, reinforcing the notion that dogs represent a potentially useful natural model of the human tumor. Dr. Peralta and his colleagues are now working to establish in vitro and in vivo models of different canine oral tumors that can be used to test potential drugs. Any drugs that might prove effective in treating oral tumors in dogs could also be promising candidates for human patients with analogue disease. Learn more about this study in Scientific Reports (2021); doi:10.1038/ s41598-021-97430-0. n FEBRUARY 2 0 2 2

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IMPRESSIONS C D A J O U R N A L , V O L 5 0 , Nº 2

Barriers To Dental Care Found in Women Enrolled in Medicaid Poor Oral Health May Impact COVID-19 Severity for Cardiac Patients The correlation between poor oral health and COVID-19 severity, as well as the correlation between oral health and delayed recovery, demonstrates a potential need to consider oral health an additional risk factor for cardiac patients who may contract COVID-19, according to a new substudy that was presented at the American College of Cardiology (ACC) Middle East 2021 hybrid meeting held Oct. 14-15, 2021. The researchers from Cairo University hypothesized that increased COVID-19 severity may be linked to poor oral health status, especially in patients with cardiovascular diseases. Using a questionnaire, the research team assessed the oral health status, severity of COVID-19 symptoms, C-reactive protein (CRP) levels and duration of recovery in 86 Egyptian heart disease patients with a confirmed COVID-19 PCR test. An oral health score was used to determine the effect of oral health on COVID-19. Data on CRP levels and COVID-19 PCR tests were collected via the questionnaire and confirmed via medical records. CRP levels are used to determine whether there is inflammation in the body. According to the researchers, the correlation between oral health and COVID-19 severity showed a significant inverse relationship, as did the correlation between oral health with recovery period and CRP values. Poor oral health was correlated to increased values of 80

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Researchers at the Virginia Commonwealth University School of Dentistry found that Medicaid-enrolled women in Virginia were half as likely to visit the dentist during pregnancy than women with private insurance, despite the availability of Medicaid pregnancy dental coverage, according to the study published in the Journal of Women’s Health. Shillpa Naavaal, BDS, MS, MPH, an assistant professor in pediatric dentistry, and colleagues co-authored the study, which explored differences in pregnancy-related oral health knowledge and barriers to dental care among reproductive-aged women by health insurance type. The study also estimated the awareness of the available Medicaid pregnancy dental coverage among Medicaid-enrolled women. For the study, participants were recruited through study flyers displayed in the waiting area of the pregnancy clinic and the dental clinic at an urban academic health center in Virginia between October 2017 and May 2018. The eligible participants were given an information sheet explaining the study and asked to complete a questionnaire. Women were eligible to participate in the study if they were 21–45 years old and a mother to a child or currently pregnant. The authors found that 1 in 3 of the women who were enrolled in Medicaid were unaware of the available pregnancy dental coverage in Virginia. They also found that almost 40% of Medicaid-enrolled women did not know that pregnancy is a period of higher risk for oral health problems. “Medicaid-enrolled and uninsured women experience barriers to accessing oral health during pregnancy at a much higher rate compared to those with private insurance,” the authors said. “This study’s findings are timely and valuable as Virginia plans to expand comprehensive dental coverage to all Medicaid-enrolled adults beginning July 2021.” Read more of this study in the Journal of Women’s Health (2021); doi.org/10.1089/ jwh.2021.0252.

CRP and delayed recovery, especially in patients with cardiac diseases. “Oral tissues could act as a reservoir for SARS-CoV-2, developing a high viral load in the oral cavity. Therefore, we recommended maintenance of oral health and improving oral hygiene measures, especially during COVID-19 infection,” said Ahmed Mustafa Basuoni, MD, cardiology consultant at Cairo University and lead author of the study. “Simple measures like practicing proper

oral hygiene, raising awareness of oral health importance either in relation to COVID-19 infection or systemic diseases by using media and community medicine, regular dental visits, especially in patients with COVID-19, and using [antimicrobial] mouthwashes [could help in] preventing or decreasing the severity of COVID-19 disease.” Learn more about the ACC Middle East 2021 meeting.

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Obesity Raises Gingivitis Risk by Inflating Growth of Bone-Destroying Cells Chronic inflammation caused by obesity may trigger the development of cells that break down bone tissue, including the bone that holds teeth in place, according to new University at Buffalo research. The study, completed in an animal model and published in October 2021 in the Journal of Dental Research, found that

excessive inflammation resulting from obesity raises the number of myeloidderived suppressor cells (MDSC), a group of immune cells that increase during illness to regulate immune function. MDSCs, which originate in the bone marrow, develop into a range of different cell types, including osteoclasts (a cell that breaks down bone tissue).

New Treatment for HPV-Associated Oral Cancer Researchers from the Mayo Clinic found that a new, shorter treatment for patients with HPV-associated oropharynx cancer leads to excellent disease control and fewer side effects compared to standard treatment. The new treatment employs minimally invasive surgery and half the standard dose of radiation therapy as current treatments. The new treatment also lasts for two weeks, rather than the standard six weeks. Results of a study of the new treatment were presented in October 2021 at the American Society for Radiation Oncology’s Annual Meeting. Daniel J. Ma, MD, a radiation oncologist at the Mayo Clinic and the study’s author, said that while the standard treatment for this type of cancer leads to high cure rates, it may also result in many short-term and long-term treatment toxicities, including dry mouth, problems swallowing, neck stiffness and jawbone problems. “Many of these side effects are directly linked to the amount of radiation used for treatment,” Dr. Ma said. Dr. Ma and his colleagues developed an initial clinical trial looking at a new treatment using minimally invasive surgery and half the standard dose of radiation. The initial clinical trial demonstrated that well-selected patients could have excellent disease control with much lower toxicity using the new treatment. Based on these phase 3 results, the Mayo Clinic has adopted this shorter course treatment as its standard of care for well-selected patients. The research team is now developing future clinical trials that will test whether it is possible to combine lower doses of radiation with other treatment strategies, such as proton beam therapy, to further reduce toxicity to patients. Learn more about the American Society for Radiation Oncology’s Annual Meeting.

“Although there is a clear relationship between the degree of obesity and periodontal disease, the mechanisms that underpin the links between these conditions were not completely understood,” said Keith Kirkwood, DDS, PhD, professor of oral biology in the UB School of Dental Medicine. “Understanding that myeloidderived suppressor cells are expanded during obesity and operate in a context-defined manner, we addressed the potential role of MDSCs to contribute toward obesityassociated periodontal disease.” The study examined two groups of mice fed vastly different diets over the course of 16 weeks. One group was fed a low-fat diet that derived 10% of energy from fat, and the other group was fed a high-fat diet that drew 45% of energy from fat. The investigation found that the high-fat diet group experienced obesity, more inflammation and a greater increase of MDSCs in the bone marrow and spleen compared to the low-fat diet group. The high-fat diet group also developed a significantly larger number of osteoclasts and lost more alveolar bone. Also, the expression of 27 genes tied to osteoclast formation was significantly elevated in the group fed a high-fat diet. The study findings may shed more light on the mechanisms behind other chronic inflammatory, bone-related diseases that develop concurrently with obesity, such as arthritis and osteoporosis, Dr. Kirkwood said. Read more about this study in the Journal of Dental Research (2021); doi:10.1177/00220345211040729.

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introduction C D A J O U R N A L , V O L 5 0 , Nº 2

Living and Practicing With COVID-19 Natasha A. Lee, DDS

GUEST EDITOR Natasha A. Lee, DDS, is a past president of the California Dental Association and the San Francisco Dental Society. During the pandemic she served on CDA’s COVID-19 Clinical Care Workgroup and the Governor’s State of California Business and Jobs Recovery Task Force. Dr. Lee maintains a private practice in San Francisco and is a part-time educator at her alma mater, the University of the Pacific, Arthur A. Dugoni School of Dentistry where she directs the practice management and jurisprudence curriculum. Conflict of Interest Disclosure: None reported.

any expected the pandemic to be over by the time this issue of the Journal was to be published in February 2022. Planning began well over a year ago, and this issue was intended to provide historical documentation of what happened in dentistry during the pandemic. This was to be a follow-up issue dedicated to dentistry and COVID-19, the first having been published in October 2020, presenting articles on emerging dental science in the midst of the pandemic. However, cases of a new SARSCoV-2 variant, omicron, are skyrocketing to levels never before seen. With the possibility of other new and highly infectious variants continuing to emerge, respiratory protection is as critical as it was at the start of the pandemic, and dentists must be ever vigilant for the frequently updated practice requirements for health care settings. We have been forced to shift our thinking from waiting for things to return to the way things were to learning how to adapt to our “new normal” of living and practicing with COVID-19, with the expectation that SARS-CoV-2

will eventually become endemic. Here, authors present articles on how dentistry has responded and adapted. Richard J. Nagy, DDS, is a periodontist who served as the president of CDA in 2020. As president, one generally expects to work on behalf of CDA member dentists, supporting them in their chosen profession and their efforts to improve the oral health of their patients. In any “normal” year, this would involve collaborating with other dentist leaders and CDA’s professional staff to address issues like dental benefits plan concerns, improving access to care, providing practice support for members, offering continuing education through CDA Presents, protecting dentists through TDIC insurance products and more. But in 2020, Dr. Nagy led a state dental association of 27,000 member dentists through a pandemic while still working to address all of the other “normal” issues facing the profession. In this Journal issue, Dr. Nagy reflects on the challenges dentistry has faced during this pandemic and how organized dentistry has responded. As dental providers, we are up close and personal in the mouths of patients while generating aerosols with our dental FEBRUARY 2 0 2 2

introduction C D A J O U R N A L , V O L 5 0 , Nº 2

equipment and instruments. Likewise, patients are exposed to us at very close range. Despite the aerosol risk, dentistry’s enhanced precautions and infection control standards have protected both dental providers and patients extremely well. Eve Cuny, MS, infection control expert and executive associate dean at the University of the Pacific, Arthur A. Dugoni School of Dentistry, discusses how infection control standards have changed in dentistry in modern times, first in response to the HIV epidemic and now in response to the COVID-19 pandemic. Many years ago, CDA recognized the importance of data collection and analysis to aid in understanding the changing dental environment, future forecasting and

evidence-based decision-making. Anders Bjork, MBA, is CDA’s vice president of strategic intelligence and analytics. He presents information on the financial impact of the pandemic on dentistry and the possible longer-term economic effects. Jay Kumar, DDS, MPH, is the state dental director, a position created several years ago as a direct result of advocacy efforts by CDA. Here, Dr. Kumar writes about his role during the pandemic as the head of the California Department of Public Health’s Office of Oral Health, touching on topics spanning from guidance for health care delivery in dental-specific settings, to concerns about how the pandemic has created additional barriers for many with limited

access to oral health care, to equitable vaccination distribution within the state. While the articles in this issue help tell the story of how the dental profession was affected by the pandemic, the story is not yet over, nor are these the last articles that will be written about dentistry and COVID-19. In a decade, we will be able to look back at what is written in this issue to understand what occurred during this crisis, but for now we can also look forward to new opportunities, advances in science and research and innovative developments that will surely be the result of our learning from this pandemic. n

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Dentistry’s Collective Strength During Unprecedented Times An assessment of organized dentistry’s response to the COVID-19 pandemic in California Richard J. Nagy, DDS

AUTHOR Richard J. Nagy, DDS, a board-certified periodontist and diplomate of the American Board of Periodontology, maintained a private practice in Santa Barbara, Calif., before becoming the director of the postgraduate periodontics residency program and department chairman at the Greater Los Angeles VA Healthcare System in 2020. He is the former editor of Periodontal Abstracts and past president of the California Society of Periodontists, the Western Society of Periodontology and the California Dental Association. Conflict of Interest Disclosure: None reported

t was March 7, 2020, and the first California Dental Association Board of Trustees meeting of the year had just been adjourned. The typical business of the association was conducted and plans were laid out for the year ahead; however, it was becoming evident that a probable pandemic was looming. Preparations were underway, and CDA had already formed two COVID-19 workgroups to address the unknowns that were sure to be arising. Soon after that meeting, it felt like all of a sudden, a distant tidal wave came crashing to shore. One of my favorite John Lennon quotes, “Life is what happens when you’re busy making other plans,” meant more in that moment than ever before. CDA’s dentist leaders and professional staff immediately got to work to

address the new events and issues that seemed to come forward daily. There wasn’t an instruction manual to guide dentistry through a pandemic, but it was the collective strength of CDA that helped create solutions. One of the first issues to address in the face of this potentially deadly airborne virus was how to ensure safety in dental offices when very little was known about the virus. Therefore, early on, dental offices were advised to limit patient care to emergencies only for what was thought would just be a few weeks. Then, on March 19, California Gov. Gavin Newsom issued an order for “all individuals living in the state of California to stay at home or at their place of residence,” with exceptions for critical service sectors, and soon after, the California Department of Public Health (CDPH) FEBRUARY 2 0 2 1

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• Live C.E. waiver issued • Virtual CDA Presents

Nov 2020

May 2020 April 2020

Stay-home order • CDA-issued reco for closure • CCWG/economic workgroups created • C.E. waiver issued • • • •

Vaccine confidence survey published

Pfizer and Moderna vaccines approved by FDA

TDIC premium refunds issued

March 2020

Vaccine confidence resources published

Jan 2021 Dec 2020

Sept 2020

CDA testing toolkit published

CDPH reopening guidance issued B2P toolkit published PPE relief grassroots campaign TDSC PPE kits distributed

• • • •

May 2021 April 2021

July 2020

Additional free PPE program

Dental teams given priority access to vaccines Vaccine toolkit published Dentists allowed to be vaccinators Vaccine scope expansion legislation introduced

FIGURE 1 . Timeline of major events during the pandemic.

mandated that all health care facilities postpone routine and elective care and treat medical and dental emergency needs only. Never did anyone think this would last for several months. CDA stepped up to provide meaningful leadership and advocacy during that time, working with the CDPH, the California Occupational Health and Safety Administration (Cal/OSHA) and the governor’s office to provide guidance for patient and practitioner clinical safety and dental practice support. This paper describes the work of CDA in meeting the profession’s needs, the strength organized dentistry was able to leverage in a variety of venues and the ability of the organization to nimbly adapt, pivot as needed and 88

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respond to the ever-changing challenges presented by the COVID-19 pandemic. FIGURE 1 above reflects the timing of major events. However, this paper discusses the topics that concerned most California dentists around these events.

Working To Get Dentistry Reopened Safely

As scientists and health experts worldwide worked to learn more about the virus, CDA quickly mobilized leadership and resources to help dentists get back to practice as safely and as quickly as possible. Two COVID-19 workgroups — Clinical Care and Economic Recovery — were appointed to sort through the science and economics and to lead the way in answering the

pressing questions: What do dentists need and how can CDA help provide it? Dr. Richard Nagy, CDA president in 2020, and State Dental Director Dr. Jayanth Kumar co-chaired the Clinical Care Workgroup, and along with representation from practicing dentists, dental school deans and educators and dental hygiene and dental assisting, worked to understand the evolving science. The workgroup developed an entire suite of resources known as “Backto-Practice,” including training videos, easy-to-use flowcharts and checklists, and along with CDA’s Practice Support experts created a resource library that also included assistance with employment questions, patient communications and navigating economic relief options.

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California Dental Association 1201 K Street, Sacramento, CA 95814 800.232.7645 | cda.org

Who’s in charge? The ‘chain of command’ for dental guidance As dentists made their way through the COVID-19 pandemic, many found the varying guidance from state and local authorities to be confusing. The following chart breaks down the roles of each of the organizations involved:

Federal Agency Center for Disease Control and Prevention The nation’s health protection agency and provides guidance on infection control protocols and the proper use of PPE.

State and Local Agencies The Governor Guides the state on when and how to modify the stay-at-home ordinance as well as other orders during the COVID-19 pandemic.

The Division of Occupational Safety and Health

California Department of Public Health

Cal/OSHA regulates workplace safety and offers recommendations on how to protect workers from COVID -19 and prevent the spread of the disease.

Takes recommendations from the governor and other regulatory agencies such as Cal/OSHA and CDC to create and issue guidance that practice owners are encouraged to comply with.

Dental Board of California Uses guidance from CDC, OSHA and other government agencies to establish regulations that are enforceable by law. The board also oversees infection control and enforces the obligation of dentists to provide a safe environment for staff and patients.

County and City Public Health Offices Receive guidance and recommendations from CDPH for local regulations. If a local ordinance is more stringent than state regulations, the local ordinance should be followed.

American Dental Association

California Dental Association

Local Dental Societies

Provides guidance to state dental associations and dental professionals across the country based on current laws and regulations. ADA is not a regulatory body and cannot issue mandates on dental practice operations.

Informs California dental professionals of current laws and regulations and offers recommendations on what would be beneficial to practice owners, their teams and patients. CDA is not a regulatory body and cannot issue mandates on dental practice operations.

Offer recommendations based on guidance to ensure each sector of dental professionals are compliant with local, state and federal regulations. Local societies are not regulatory bodies and cannot issue mandates on dental practice operations.

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These resources have more than 375,000 page views on CDA’s website. These efforts added to those that already existed within CDA’s Practice Support, where staff provide members free and unlimited access to expertise and resources on the following four areas of dental practice: dental benefits, regulatory compliance, employment and practice management. During the first year of the pandemic, Practice Support staff continued providing one-on-one guidance to dentists via email and phone, logging more than 8,000 unique member contacts in 2020. What’s more, throughout the pandemic, Practice Support staff provided numerous resources and continuous interpretation of the ever-evolving guidance from the Centers for Disease Control and Prevention (CDC), the CDPH and Cal/ OSHA to ensure dentists could practice safely and maintain compliance. Dr. Kumar’s 2015 appointment as California state dental director and the creation of a high-functioning state oral health program were top priorities of CDA’s Access to Care Plan goals and the result of significant advocacy. Though it was clear the state needed strong dental public health leadership to achieve improvements in population oral health, it was difficult to imagine how important the state dental director’s role would be in a pandemic. Working closely with Dr. Kumar, CDA leaders and advocacy staff were able to represent at the highest levels of government what dentists were experiencing and create back-to-practice resources that were practical and effective. Clear, dental-specific guidance was essential, as during the early stages of the pandemic numerous agencies, including the World Health Organization (WHO), the U.S. Occupational Health and Safety Administration (OSHA) and the CDC, were all issuing guidance for health care 90

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providers. As much of it was focused on hospitals and others treating patients who were ill, dental practices needed guidance specifically for providing oral health care during the pandemic. This made good communication with the CDPH and Cal/OSHA essential. On May 7, 2020, the CDPH released guidance specifically for dental practices returning to routine care, including specific criteria regarding local infection rates, PPE requirements, COVID-19 screenings for patients and infection control clarifications from the CDC, among other topics.

Dental practices needed guidance specifically for providing oral health care during the pandemic.

shelter-in-place orders were implemented, the COVID-19 Information Center was created and located on cda.org to provide resources on precautions and compliance. Additionally, a weekly president’s informational video, a COVID-19 newsletter to share latest news updates, Practice Support resources and educational opportunities were developed. Not long after, “virtual membership meetings” were introduced to answer dozens of member dentists’ questions related to practicing during the pandemic, including personal protective equipment (PPE) and infection control requirements, advocacy efforts, testing, patient management and other topics. Afterward, Facebook Live events were launched to quickly share with dentists the latest on PPE efforts, employment law guidance as employees were returning to work and financial relief grant and loan programs.

Addressing the PPE Shortage Additionally, local, county and city governments responded with their own ordinances on mask wearing, social distancing and eventually vaccination and testing, adding confusion about where to look for appropriate guidance. CDA monitored local public health ordinances and mandates in all 58 California counties and provided education and clarification for members to ensure compliance with all applicable rules (FIGURE 2 ). What’s more, early in the pandemic, there was a quick pivot to digital-first communications versus print to ensure that dentists would receive the most up-to-date, accurate information because news was evolving quickly and at times so quickly that there were multiple updates within a day. Almost immediately after

As experts confirmed the risk of SARS-CoV-2 infection through respiratory transmission, proper airway protection became essential for dental office personnel. This meant the use of properly fitted N95 respirators or similar or higher levels of respiratory protection for all clinical dental staff. However, N95 shortages occurred almost immediately, as the need within health care exploded at the same time that production stalled and supply chains clogged. Emergency-use alternatives were described by the CDC, and dentistry implemented the extended and reuse of N95s, purchased KN95s and in some cases tried to adapt personal airpowered respirators (PAPRs) for dental treatment. Even when N95s or KN95s could be found, the requirements for medical evaluation and fit testing posed

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challenges to quickly meeting these new respiratory protections for dentistry. To directly assist dentists with respirator shortages, CDA and The Dentists Supply Company (TDSC) worked with the governor’s office to procure millions of N95s from a state stockpile in Fresno, California. TDSC, which was launched in 2017 as a subsidiary of CDA to provide members with an online marketplace of discounted dental supplies, was the perfect partner to manage, track orders and distribute these respirators quickly and efficiently to dentists throughout California. Trucks were sent to Fresno to pick up supplies and bring them to the TDSC distribution center in Reno, Nevada. All were excited to let dentists know that these precious respirators were ready to be distributed. Then, hours before dentists were to be informed and distribution to begin, the state took back the N95s. Needless to say, disappointment and frustration ensued, but the work to find more respirators and other PPE had to continue. Later, two massive distributions of state-supply PPE were acquired and distributed to California dentists via TDSC. Local dental component societies were also instrumental in locating, securing and distributing PPE, often working with county authorities to obtain supplies for dentists. As acquiring PPE was especially difficult during the earliest months of the pandemic, TDSC learned to be critical and scrutinize the quality of available PPE amid concerns that global supplies increasingly included counterfeit products that risked failing required safety standards. Searching for safe PPE continued into 2021 when CDA partnered with the California Medical Association to help further distribute

PPE from the state stockpile at only the cost of shipping. To date, over 25,000 PPE kits worth more than $11.5 million have been distributed to dentists. Though respirators were the earliest source of PPE strain on dental practices, gloves and gowns quickly followed, as the slowdown in production and distribution channels affected all types of PPE. As expected, increased demand and decreased supply led to steep price increases, and dentists found themselves paying up to 10 times more for these items than before the pandemic.

To date, over 25,000 PPE kits worth more than $11.5 million have been distributed to dentists.

Although TDSC transitioned to a new parent company, Henry Schein, in 2020, its original mission to serve state dental association members with everyday low prices for dental supplies was birthed by CDA’s commitment to assist dental practice success by lowering operating costs and successfully saved member dentists over $5 million in its early years. That it became an important partner for securing and distributing PPE during the pandemic was not something CDA could have anticipated but was certainly a plus for California dentists. Besides assisting dentists with PPE, CDA proactively communicated with state regulators to ensure they understood dentistry’s exceptional history of preventing disease transmission during the provision of dental care and

successfully advocated to provide clear infection control and safety protocols that would get dentists back to work quickly and safely during the pandemic.

Assuring Patient Confidence in Returning to Dental Care

Additionally, CDA sponsored “Keep Smiling California,” a dental health awareness campaign to provide information to patients and build their confidence to return to the dentist. This included consumer research to gauge patient comfort with visiting the dentist during the pandemic. From these findings and the increase in misinformation about dental office safety, it became very clear that something needed to be done to let patients know that it was safe to go to the dentist. Therefore, statewide media interviews were conducted by CDA member dentists to educate the public on the safety and importance of dental care during the pandemic. This helped to further establish public awareness about the safety of dental care through well known, respected and widely viewed media including “Good Morning America,” The Washington Post, National Public Radio, several statewide newspapers and local television and radio outlets.

Helping To Solve Workforce Challenges

When dental practices were advised to provide only emergency treatment in the first few months of the pandemic, practice owners were faced with how to address their employees’ work status. Some terminated all staff and paid out remaining benefits, but most of the time, staff who could work from home did and others were placed on “furlough.” During this period, communication between employers and employees was essential, as there were times when furloughed staff were asked to return to the office to FEBRUARY 2 0 2 2

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assist in providing immediate palliative or emergency care. CDA assisted dentists who had to furlough employees with resources on required documentation (e.g., sample furlough letter) and how to stay connected to their teams through social and communication channels. Naturally, employees had many questions too, and CDA’s Practice Support experts provided a wealth of HR guidance, including links, tips and webinars for employers and employees on Pandemic Unemployment Assistance (PUA) benefits, Supplemental Paid Sick Leave benefit laws and the complex benefits employers could offer employees who were affected by COVID-19 through illness, exposure or caretaking. At the statewide level, Dr. Natasha Lee, CDA past president, dental educator and private practice owner, was appointed to the Governor’s Task Force on Business and Jobs Recovery to ensure dentistry’s concerns were represented with state economic and workforce agencies. Dental office staff shortages, especially for dental assistants, which had been an issue prior to the pandemic, became a significantly greater issue during the pandemic. A CDA economic recovery workgroup was developed that focused on increasing awareness of dental careers and recruitment. Furthermore, the pandemic caused a significant amount of job loss in the restaurant, retail and travel industries. Recognizing that the service orientation and people skills required for jobs in these fields were well-suited for dental assisting and those recently unemployed may be interested in retraining, CDA worked with state workforce experts on plans to recruit and retrain interested individuals. In the last quarter of 2020, CDA executed three strategies to support members in this area, including a dedicated marketing and 92

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PR campaign focused on stimulating interest in a career in dental assisting, intensive curriculum development focused on dental assistant training and the launching of a new career center on cda.org to connect member dentists with job seekers. Included in the marketing campaign, “SmileCrewCA. com” was created to allow interested individuals the opportunity to learn more about a career in dental assisting as well as submit their information for interest in the training program. Since this launch, CDA has piloted four

A CDA economic recovery workgroup was developed that focused on increasing awareness of dental careers and recruitment.

dental assisting training bootcamps in the Bay Area and San Diego, with additional locations on the way.

Supporting Financial Relief Efforts

CDA’s usual focus on the state legislative and regulatory environment quickly expanded to include both federal and local efforts as all levels of government frantically responded to the pandemic. Congress passed multiple rounds of economic stimulus packages in 2020, including the Families First Coronavirus Response Act (FFCRA) and the $2.2 trillion Coronavirus Aid, Relief and Economic Security (CARES) Act, both signed into law in March 2020. These bills included direct payments to individual taxpayers, small business loans, vaccine response and development

and PPE purchasing and manufacturing as well as paid sick leave and unemployment benefits for workers and families. Additional legislation through 2020 and 2021 extended programs and provisions of the CARES Act and implemented additional relief packages. The small business loans available to dentists included the Economic Injury Disaster Loan (EIDL) and Paycheck Protection Program loan (PPP). The rules and requirements, application processes and deadlines unfolded as the federal government worked to quickly implement these programs. CDA provided feedback to Congress and federal administrators where possible to get stimulus easily and quickly to dental offices, and Practice Support staff advised dentists on the changing and often confusing requirements for each phase of these programs. The Provider Relief Fund (PRF) was also established by Congress through the Department of Health and Human Services to help health care providers suffering economic losses due to COVID-19. These funds initially targeted Medicare and Medicaid providers, with additional rounds of funding being opened to all dentists, newly practicing dentists and rural dentists. In total, the four phases of PRF made $117.5 billion available to health care providers including dentists. Legal analysis along with robust communication to members was essential to keep dentists and their offices up to speed with new rounds of funding, loan opportunities, extended deadlines, evolving compliance requirements and changing requirements for sick leave and unemployment. CDA received numerous calls and emails from financially stressed member dentists early in the pandemic and took quick action to develop

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RESOURCES

Essential Vaccine and Testing Toolkits CDA’s Vaccine Confidence Toolkit was created to keep dentists and the dental team up to date on the COVID-19 vaccine, immunization best practices, how to talk to patients about the vaccine and more.

programs and options that would provide guidance and relief. Among those were extending the membership dues grace period, waiving fees for CDA online continuing education, providing no-cost access to audio recordings from prior CDA Presents events, and with Bank of America, one of CDA’s endorsed partners, allowing dentists to defer loan payments. Further, The Dentists Insurance Company (TDIC), CDA’s insurance subsidiary, understanding concerns related to lost income from office closures and other pandemic related challenges, quickly offered dentists economic relief and guidance. This included such things as issuing policyholders nearly $6 million in premium refunds in 2020, reducing fees for online risk management seminars and temporarily waiving fees for credit cards and insufficient funds. Furthermore, TDIC sponsored financial health webinars featuring expert speakers plus one-on-one guidance. These actions helped to keep dentists adequately covered and able to continue providing care as the profession adjusted to the financial havoc the pandemic created on all sectors of society.

Advocating for Dental Benefits Reimbursement

CDA also worked with dental benefits companies to secure relief and financial support for dentists. As part of this advocacy, CDA successfully sponsored legislation (SB 242) to require private health care plans to reimburse contracting health care providers for their business expenses to prevent the spread of respiratorytransmitted infectious diseases causing public health emergencies declared on or after Jan. 1, 2022. Though this could not be retroactive to COVID-19,

The Laboratory Testing Toolkit CDA developed provides application instructions, reporting requirements and guidance for dentists to decide if administering rapid COVID-19 tests is appropriate for their practice.

should dentistry face another similar pandemic, costs incurred by dental practice owners for respiratory protection, such as N95s, would be reimbursable. Through that work, seven grassroots action campaigns were organized for varying COVID-19 relief efforts, with more than 7,180 CDA member dentists and advocates responding to CDA’s request to send communication to lawmakers requesting passage of COVID-19 relief legislation affecting dentistry. Successful advocacy efforts also turned a potential loss of Proposition 56 funding (California’s Healthcare, Research and Prevention Tobacco Tax Act of 2016) into a win, which resulted in preserving the state’s dental student loan repayment program, State Office of Oral Health funding and Medi-Cal Dental Program provider supplemental payments.

Supporting Students and New Dentists

The pandemic not only disrupted dental practices, but also created a bottleneck for dental students on the precipice of graduation. With so much still unknown about the virus, nearly all dental schools in the country canceled the patient-based examinations required for licensure in California. In turn, all major dental examining agencies began to offer mannikin-based examinations. However, the Dental Board of California remained uncertain that it could accept test results from a new examination method without legislative action. The time was certainly ripe for California to move away from patientbased exams. Many educational and student groups have long advocated for the elimination of patient-based examinations due to the ethical and

financial issues associated with obtaining patients with qualifying oral disease and the continuation of that care beyond the date of examination. CDA worked closely alongside California’s dental schools, successfully advocating to secure a timely pathway for dental licensure for 800-plus dental students graduating during the pandemic. The results of this advocacy will be long lasting, as the state will now permanently accept mannikin-based examinations in addition to patient-based exams. Because of this, CDA was honored with a Gies Award for achievement by a public or private partner. Given annually by the American Dental Education Association Gies Foundation, the Gies Award honors individuals and organizations that exemplify the highest standards in oral health and dental education, research and leadership.

Providing Continuing Education and License Renewal Support

With various shelter-in-place orders executed throughout the state, the ability for dental health professionals to attend in-person continuing education courses was drastically reduced, putting licensees in jeopardy of failing to meet licensure renewal requirements and preventing them from continuing to practice and provide care to patients. CDA responded to this concern with successful advocacy that gave all health care licensees an adequate extension to complete C.E. units for renewal and a waiver to allow virtual courses to meet the requirements for live C.E. for the duration of the governor’s declared state of emergency. Additionally, CDA continued to provide educational content to FEBRUARY 2 0 2 1

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members despite the cancellation of CDA Presents in 2020. While a large, in-person event was unsafe to host at the time, CDA pivoted its offerings to include over 20 live and recorded webinars on dentistry and COVID-19 to help dentists navigate practicing in the pandemic. Further, the semiannual CDA Presents was adapted into a virtual convention with over 40 C.E. courses and an interactive exhibit hall that was attended by more than 5,700 attendees. This experience challenged past views of educational offerings and propelled CDA to prioritize accessible resources for all members through various online and hybrid learning opportunities.

Evaluating COVID-19 Testing Feasibility in Dental Practices

In California, COVID-19 testing is within the scope of practice for dentists when used for screening for COVID-19 rather than for providing a formal COVID-19 diagnosis. However, in order to conduct a rapid, in-office COVID-19 test, a dentist must first obtain Laboratory Field Services (LFS) testing licensure required by the state and Clinical Laboratory Improvement Amendments (CLIA) licensure required at the federal level. Prior to the pandemic, dentists were not eligible to apply for state lab licensure despite being eligible at the federal level. CDA quickly worked with the state legislature to sponsor a bill that created parity with state and federal law and ultimately permitted dentists to conduct rapid testing on both patients and staff. However, it was not always certain whether testing technology would advance sufficiently to provide dental settings with a test that was rapid enough to screen real time and sensitive, accurate and affordable enough to provide to all patients. Eventually, a handful of rapid tests became available to health care 94

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providers; however, while the tests were fast, they were still unable to detect infection within the first few days of exposure, making testing still inadequate to ensure a patient’s COVID status and eliminate any PPE requirements. Complicating matters, as the state began to reopen in 2020, and prior to the approval and availability of rapid tests, many local health departments considered mandating negative test results prior to obtaining dental services. Because dentists were not yet able to obtain lab licensure and test results were

Initial rollout plans for vaccines did not include dental offices in parity with physician offices or hospitals.

typically obtained one to five days after specimen collection at community testing sites, this requirement would have posed a significant barrier to care. CDA and local dental societies successfully advocated against these proposed requirements so that dentists could continue to screen patients through temperature checks and previsit questionnaires. Appropriately screening patients for infectious disease prior to performing dental treatment is the standard of care and a Cal/OSHA requirement; though absent federal or state guidance, determining how that screening occurs and whether to implement in-office rapid tests remains at the dentist’s discretion. However, the state’s decision to issue public health orders requiring dental office staff to either provide

proof of COVID-19 vaccination or submit weekly negative COVID-19 tests to their employer has created an additional need for dental offices to have the option to test on-site. Further, while testing patients directly assists dentists with dental treatment or referral decisions, it has the additional advantage of identifying potentially positive individuals early in the disease process, facilitating referral to a medical professional for diagnosis and intervention and contributing to public health surveillance and contact tracing efforts.

Defining Dentistry’s Role in Vaccination Efforts

Once COVID-19 vaccinations became available, the state had to manage a shortage of doses against an increasingly large group of employees advocating for front-line worker status. From hospitals to grocery stores, nearly all industries were seeking prioritized access to vaccine doses. Initial rollout plans for vaccines did not include dental offices in parity with physician offices or hospitals. CDA’s participation in a statewide community vaccine committee led by the state epidemiologist in addition to successful CDA advocacy secured not only priority access to COVID-19 vaccines for dentistry, but also obtained an emergency waiver for dentists, hygienists and dental students to serve as temporary vaccinators, largely at mass vaccination sites and at some dental schools. What’s more, CDA successfully sponsored legislation to permanently codify this scope expansion for dentists to also include flu vaccines. At the same time, partnership with the CDPH and the Office of Oral Health has led to creating vaccine confidence resources and tools to increase vaccination rates

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among dental teams and patients. Part of this work included a vaccine confidence survey, which resulted in findings that as of July 2021, 94% of dentists in California were vaccinated, making California dentists the most vaccinated group of health care professionals in the country.

Conclusion

Only the highlights of the extraordinary amount of work completed through organized dentistry by CDA volunteer leaders in collaboration with CDA staff during the COVID-19 pandemic have been presented here. There was a great amount of additional time and effort invested behind the scenes, work which continues today. Thank you to the countless individuals who gave their time and expertise, for together it made a difference for dentists, their teams, their patients and their practices. CDA’s continued, proven support of the profession serves as a case study for the value of organized dentistry. CDA’s mission throughout the COVID-19 pandemic is the same as it’s been for over 150 years: To be limitless in our support and advocacy for our members. Together through strength in numbers, our 27,000-member strong California Dental Association continues to pave the way forward for the profession of dentistry and the oral health of Californians. n AC KN OW LEDGM EN T The author thanks CDA staff in Public Affairs and Practice Support for their contributions. TH E AU THO R , Richard J. Nagy, DDS, can be reached at nagyperio@gmail.com.

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Healthy Patients

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that your business flourishes. It’s why we deliver the supplies you love

from brands you trust. It’s why we offer free shipping on orders over $99.

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C.E. Credit

Safe Dental Care During the COVID-19 Pandemic Eve Cuny, MS

AUTHOR Eve Cuny, MS, is executive associate dean at the University of the Pacific, Arthur A. Dugoni School of Dentistry. She is an internationally recognized expert in patient safety and infection control. Conflict of Interest Disclosure: None reported.

he COVID-19 pandemic has challenged the world in unprecedented ways. Never in our lifetime have we seen such massive shutdowns of businesses, waves of illness followed by waves of deaths periodically overwhelming the most advanced medical systems in the world and a near halt to global travel that all occurred during the spring and summer of 2020. Dentistry in the U.S. was profoundly impacted during the early months of the pandemic. According to a survey conducted by the American Dental Associate (ADA) Health Policy Institute, 19% of dental offices were completely shut down by March 23, 2020, and 76% offered only emergency care.1 As the profession began planning a return to patient care, dental health care personnel (DHCP) and patients had many questions about maintaining infection control in the midst of a pandemic. Of particular concern were procedures that are known to generate aerosols, such as ultrasonic scaling, highspeed handpieces and air/water syringes.2

Evolution of Infection Prevention Practices in Dentistry

DHCP who were part of the profession in the 1980s will remember the uncertainty and fear of that time due to another emerging viral disease, HIV. Despite numerous clusters of hepatitis B viral infection associated with dental settings, standards and guidelines for

infection control practices in oral health care settings were very limited before the mid-1980s.3–9 Particularly alarming to patients was the report of a possible transmission of HIV from an infected dentist to one of his patients in 1990.10 Follow-up investigation by the Centers for Disease Control and Prevention (CDC) in 1991 resulted in an additional four patients being identified as HIV positive.11 At least three of these five patients had viral strains that were closely linked to that of the HIV-infected dentist who had performed extractions and other routine dental procedures for these three patients. A review of the dental team’s infection control practices revealed some lapses in recommended practices. These included sometimes washing gloves instead of changing between patients, handpieces wiped with alcohol rather than heat sterilized and single-patientuse items occasionally disinfected for reuse on subsequent patients. The investigation also pointed out that the dentist received prophylactic treatment from the dental hygienist in the practice. The dentist did not keep records of accidental percutaneous injuries, so it was unclear whether he had potentially sustained a sharps injury that could have caused bleeding while working intraorally or if a handpiece or other device or instrument used during his prophylaxis could have spread contamination from him to subsequent patients.11 FEBRUARY 2 0 2 2

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OSHA Risk Pyramid

Low risk

Moderate risk

High risk

Very high risk

Administrative duties.

Urgent or emergency care without aerosols.

Aerosol-generating procedures on well patients. Any procedure on COVID-19 patients.

Aerosol-generating procedures on known or suspected COVID-19 patients.

FIGURE 1. Adapted from U.S. Department of Labor. OSHA. Guidance on preparing workplaces for COVID-19. COVID-19 - Control and Prevention /Dentistry Workers and Employers.

In 1986, the CDC issued its first guidance on infection control in dental health care settings.12 This brief document with 21 references was the first official recommendation for DHCP to wear personal protective equipment (PPE), routinely sterilize handpieces, decontaminate surfaces between patients and use care in the handling of sharp contaminated instruments and needles. These guidelines were updated and expanded in 1993 and again in 2003 with stronger recommendations regarding disinfection and sterilization, management of dental unit attachments and dental waterlines, disposal of singleuse disposable instruments, safe use of lasers and handling of biopsy specimens in addition to others.13,14 The 2003 infection control guidance was the most comprehensive yet, with more than 470 references, a working group consisting of six authors, a large advisory group, CDC consultants and other federal consultants. 98

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Dental Infection Control in the Era of COVID-19

By the middle of March 2020, the number of new cases of COVID-19 in the U.S. was doubling every six days. Health authorities became alarmed that unchecked growth in new cases would quickly overwhelm existing health systems with sick and in some cases dying patients. With a virus that had quickly turned into a pandemic, the Occupational Safety and Health Administration (OSHA), the ADA and the CDC all cautioned dentists to limit care to the most essential needed for patients with pain or infection.15–17 Of particular concern were aerosol-generating procedures (AGP) common in dentistry that have the potential to carry infected particles longer distances (FIGURE 1 ). By the end of March 2020, many county and state health departments were requiring dental practices to suspend provision of routine dental care and limit procedures to urgent or emergency needs only. What

was needed was a close look at existing evidence-based precautions for droplet and airborne pathogens to develop reasonable infection control practices to prevent the spread of COVID-19 in a patient care environment that generates aerosols and droplets containing oral fluids. As the U.S. and the rest of the world dealt with the first wave of the pandemic, DHCP looked for answers to pressing questions about how to safely return to performing patient care. Amid a pandemic caused by a virus thought to spread primarily through droplets released from a person’s mouth, the prior CDC guidance for dentistry to use standard precautions during dental procedures was likely not adequate to protect against transmission via the droplet or airborne route. Standard precautions are only intended to protect against disease transmission that could result from direct or indirect contact of infected body fluids with a DHCP’s mucous membranes or nonintact skin or via a percutaneous injury with a contaminated device or instrument. Standard precautions are used in the care of all patients regardless of known or suspected infection.18 Transmissionbased precautions are the next level of infection control practices that are used in addition to standard precautions for patients who may be infected or colonized with certain pathogens for which additional precautions are needed, such as those spread by the droplet or airborne route.19 Elements of transmission-based precautions were added to the CDC interim infection control guidelines. Because all potentially infected individuals cannot be identified through screening and testing, certain precautions are necessary to reduce the risk of transmission in the dental setting. As dental offices began to resume more patient care through the remainder of 2020, the CDC and the ADA regularly updated

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TABLE 1

Standard and Transmission-Based Precautions Type of precaution Standard precautions

guidance on how to safely manage patient care. This included a focus on ventilation, pandemic-specific precautions such as distancing, screening, testing patients prior to certain procedures and enhanced PPE for DHCP. Many of these new precautions are elements of transmission-based precautions (TA BLE 1). The use of respirators (including N95 respirators), PPE donning and doffing sequences, ventilation control and patient positioning are all recommended for treating patients in dental settings during the pandemic and are elements of transmission-based precautions. These appear to have been effective control measures as evidenced by the low number of reported clusters of infection associated with dental practices and some limited studies of prevalence of infection among dentists.20

• • • • • • •

Transmission routes

Hand hygiene Personal protective equipment Respiratory hygiene/cough etiquette Sharps safety Safe injection practices Sterile instruments and devices Clean and disinfected environmental surfaces

Direct or indirect contact with patient body fluids (e.g., percutaneous injury, nonintact skin of DHCP, splash to mucous membranes of DHCPs’ eyes, nose or mouth).

Transmission-based precautions Contact precautions

• Appropriate patient placement • Minimize movement of patient within the facility • Gown and gloves for all interactions with the patient and their care environment • Disposable or dedicated patient care equipment • Prioritized cleaning and disinfection of frequently touched (by the patient) surfaces

Increased risk of transmission via contact (e.g., MRSA).

Droplet precautions

• • • •

For patients known or suspected of being infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing or talking (e.g., common cold, meningitis, mumps).

Airborne precautions

• Source control (mask on patient) • Patient placement in airborne infection isolation room (AIIR) • Restrict susceptible personnel from having contact • Use PPE including a fit-tested NIOSH-approved N95 or higher-level respirator • Limit movement of patient outside of AIIR

California-Specific Requirements

The COVID-19 pandemic also warranted a closer look at the existing OSHA regulations related to airborne transmissible diseases. In its guide to aerosol transmissible diseases, Cal/OSHA addresses the need for specific controls to reduce the risk of airborne disease transmission to exposed workers (ATD standards). Though California dental practices have historically been exempt from the respiratory protection required by ATD standards due to an ability to accurately screen for airborne illnesses, such as measles, and defer treatment, consistently high levels of community transmission of SARS-CoV-2 and its ability to be carried and transmitted by asymptomatic individuals who cannot be reliably identified through screening radically altered the level of respiratory protection required for dental treatment during the pandemic. Clinical dental personnel are required to wear respiratory protection during the provision of aerosol-generating dental procedures

Key elements

Source control (mask on patient) Place patient in a single room Don mask upon entering patient room Limit movement of patient within the facility

• For patients known or suspected to be infected with pathogens transmitted by the airborne route (e.g., COVID-19, tuberculosis, measles, chickenpox, disseminated herpes zoster).

Adapted from CDC Infection Control. Transmission-Based Precautions.

unless they can meet the four specific conditions outlined in TA BLE 2 for ATD exemption. Additionally, dental offices were required to amend their illness and injury prevention plans (IIPP) to include COVID19-specific information. On July 26, 2021, the California Department of Public Health issued an order requiring all health care facilities, including dental offices, to verify the vaccine status of all workers in the facility. Proof of vaccination includes the

official vaccination record card, a photo of the card or an image stored on a phone or electronic device, a digital vaccine record that includes a QR code or documentation of COVID-19 vaccination from a health care provider. Unvaccinated or partially vaccinated workers are required to undergo weekly diagnostic screening testing with either antigen or molecular (PCR) tests. The dental practice must have a plan for tracking both the vaccination status of employees and the results of testing.20 FEBRUARY 2 0 2 2

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TABLE 2

Exemptions to Cal/OSHA Airborne Transmissible Diseases Standard for Dental Clinics Outpatient dental practices are not required to comply with this regulation if they meet these four conditions: 1. Dental procedures are not performed on patients identified to them as ATD cases or suspected ATD cases. 2. The employer establishes and implements a written procedure consistent with current guidelines from the Centers for Disease Control and Prevention (CDC) to screen patients prior to performing any dental procedure on them to determine the risk of exposure to ATD from that patient. 3. The employer trains their employees on the screening procedure. 4. Aerosol-generating dental procedures are not performed on patients who have been identified in the screening process as being a possible ATD exposure risk unless a licensed physician determines that the patient does not currently have an ATD. From The California Workplace Guide to Aerosol Transmissible Diseases. Cal/OSHA 2020. Accessed at www.dir.ca.gov/dosh/dosh_publications/ATD-Guide.pdf on Dec. 8, 2021.

Safe Dental Care

The question regarding the safe delivery of oral health care may well remain on the minds of some patients and DHCP. There is some evidence to show that the risk of spreading COVID-19 in dental settings is not greater than that of the community in general.21 In a six-month longitudinal study published in the Journal of the American Dental Association,21 results of six surveys collected over a six-month period (June 2020 to November 2020) showed that the infection prevalence rate among dentists was 2.6%. The rate of infection per month among these dentists ranged from 0.2% to 1.1%. It is important to note that this is self-reported COVID-19 positivity and some respondents could have had asymptomatic infections. A large study carried out by the National Institutes of Health from May 2020 to July 2020 found that estimated seroprevalence for COVID-19 was anywhere from 1.6% to 14.2%, depending on demographics such as age, location and race.22 Because these two studies were done within a similar time period, prevalence among dentists as a group appears to be on the low side.

Conclusion

Interim CDC infection control guidelines to control the spread of COVID-19 encompass all health professions, including dentistry. There are no longer separate interim guidelines from the CDC for providing dental care, 100

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signaling a positive trend toward inclusion of dentistry as part of the health care system in the U.S.23 These guidelines provide a path to continued safe delivery of patient care in all settings, including dental. The guidelines outline precautions including vaccination, source control, isolation for infected individuals, NIOSHapproved N95 or equivalent respirators for aerosol-generating procedures, ventilation, testing and other important considerations. DHCP can continue to provide safe care to patients and a safe work environment for the dental team. n RE FE RE N CE S 1. American Dental Association. COVID-19: Economic Impact on Dental Practices (Summary Results). Health Policy Institute. Apr 3, 2020. Accessed Sept. 9, 2021. 2. Occupational Safety and Health Administration. Hazard recognition. 2020. Accessed Sept. 9, 2021. 3. Ahtone J, Goodman RA. Hepatitis B and dental personnel: Transmission to patients and prevention issues. J Am Dent Assoc 1983 Feb;106(2):219–22. doi: 10.14219/jada. archive.1983.0416. 4. Hadler SC, Sorley DL, Acree KH, et al. An outbreak of hepatitis B in a dental practice. Ann Intern Med 1981 Aug;95(2):133–8. doi: 10.7326/0003-4819-95-2-133. 5. Centers for Disease Control and Prevention. Hepatitis B among dental patients – Indiana. MMWR 1985;34:73–5. 6. Levin ML, Maddrey WC, Wands JR, et al. Hepatitis B transmission by dentists. JAMA 1974;228:1139–40. doi:10.1001/jama.1974.03230340041029. 7. Rimland D, Parkin WE, Miller GB, et al. Hepatitis B outbreak traced to an oral surgeon. N Engl J Med 1977 Apr 28;296(17):953–8. doi: 10.1056/ NEJM197704282961701. 8. Goodwin D, Fannin SL, McCracken BB. An oral surgeonrelated hepatitis B outbreak. Calif Morbid 1976;14. 9. Reingold AL, Kane MA, Murphy EL, et al. Transmission of hepatitis B by an oral surgeon. J Infect Dis 1982 Feb;145:262–8. doi: 10.1093/infdis/145.2.262. 10. Centers for Disease Control and Prevention. Possible

transmission of human immunodeficiency virus to a patient during an invasive dental procedure. MMWR 1990;39:48993. 11. Centers for Disease Control and Prevention. Epidemiological notes and reports update: Transmission of HIV infection during an invasive dental procedure – Florida. MMWR 1991;40(2):21-27,33. 12. Centers for Disease Control and Prevention. Recommended infection-control practices for dentistry. MMWR 1986;35:237-42. 13. Centers for Disease Control and Prevention. Recommended infection-control practices for dentistry, 1993. MMWR 1993;42(No. RR-8). 14. Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings – 2003. MMWR 2003;52/No.RR-17. 15. Occupational Safety and Health Administration. COVID-19 control and prevention. Dental workers and employers. 2020. Accessed Sept. 11, 2021. 16. Centers for Disease Control and Prevention. Coronavirus Disease 2019. Dental settings. Interim infection prevention and control guidance for dental settings during the COVID-19 response. March 26, 2020. 17. Burger D. ADA recommending dentists postpone elective procedures. ADA News. 18. Centers for Disease Control and Prevention. Infection control. Standard precautions for all patients. Accessed Sept. 12, 2021. 19. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. 20. CDPH. Health Care Worker Protections in Hight-Risk Settings. July 26, 2021. Order of the State Public Health Officer Unvaccinated Workers In High Risk Settings (ca.gov). Accessed Dec. 8, 2021 21. Araujo MWB, Estrich CG, Mikkelsen M, et. al. COVID-19 among dentists in the United States. A six-month longitudinal report of accumulative prevalence and incidence. J Am Dent Assoc 2021;152(6):425–433. doi: 10.1016/j. adaj.2021.03.021. PMCID: PMC8142320.22. National Institutes of Health. NIH study suggest COVID-19 prevalence far exceeded early pandemic cases. Accessed Sept. 14, 2021. 23. Centers for Disease Control and Prevention. COVID-19. Infection Control Guidance. Sept. 10, 2021. Accessed Sept. 13, 2021. T HE AU T HOR , Eve Cuny, MS, can be reached at ecuny@pacific.edu.

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C .E. CREDIT QUESTIONS

February 2022 Continuing Education Worksheet

This worksheet provides readers an opportunity to review C.E. questions for the article “Safe Dental Care During the COVID-19 Pandemic” before taking the C.E. test online. You must first be registered at cdapresents360.com. To take the test online, please click here. This activity counts as 0.5 of Core C.E.

1. In what year did the U.S. Centers for Disease Control and Prevention issue its first guidance on infection control in dental health care settings? a. 1978 b. 1982 c. 1986 d. 1989 2. The CDC’s first set of infection control guidelines for dental health care personnel included all of the following disease transmission precautions except: a. Use of PPE b. Routine handpiece sterilization c. Environmental surface decontamination d. Dental waterline management e. Sharps safety 3. By the end of March 2020, many state and county health departments required dental practices to temporarily suspend provision of routine dental care and limit care to urgent or emergency dental needs because: a. It was necessary to evaluate existing evidence-based precautions for droplet and airborne pathogens considering the COVID-19 pandemic. b. Time was needed to develop the infection control practices necessary to prevent the spread of COVID-19 in a patient care environment that generates aerosols and droplets that contain oral fluids. c. Dental offices were operating under standard precautions guidelines, which were likely inadequate for protecting against transmission of COVID-19. d. All of the above.

4. All of the following statements are true regarding standard precautions except: a. Standard precautions are used in the care of all patients regardless of known or suspected infection. b. Standard precautions are intended to protect against disease transmission that could result from direct or indirect contact of infected body fluids with a dental provider’s mucous membranes or broken skin. c. Standard precautions are intended to prevent disease transmission through percutaneous injury with a contaminated device or instrument. d. Standard precautions are intended to protect against respiratory droplet and airborne disease transmission. 5. Which of the following is not part of standard precautions protocols? a. Hand hygiene b. Aerosol management c. PPE d. Safe injection practices e. Sterile instruments and devices 6. Transmission-based precautions include specific recommendations for contact, droplet and airborne routes of disease transmission. Standard precautions are more comprehensive for all routes of transmission and build upon transmission-based precautions. a. Both statements are true. b. Both statements are false. c. Only the first statement is true. d. Only the second statement is true. continued on next page

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C .E. CREDIT QUESTIONS

February 2022 Continuing Education Worksheet, continued

7. Which of the following protocols for treating patients in a dental office were added during the pandemic and are part of transmission-based precautions? a. Routine patient screening b. Ventilation control c. Use of respirators, such as N95 respirators d. All of the above 8. The new transmission-based precautions implemented during the COVID-19 pandemic: a. Appear to be effective in controlling COVID-19 transmission in dental offices based on preliminary studies and dentist self-reported rates of COVID-19 infection. b. Appear to have been only minimally effective in controlling clusters of COVID-19 outbreaks among dental health care personnel. c. Appear to have done very little in preventing transmission of COVID-19 in dental offices.

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9. Patients known or suspected to be infected with pathogens that can be transmitted through airborne routes and cause diseases such as measles, tuberculosis or COVID-19 should be: a. Treated in the dental office using standard precautions. b. Treated in the dental office using droplet transmissionbased precautions. c. Referred for treatment to a facility that has an airborne infection isolation room. 10. According to the OSHA Risk Pyramid, which of the following are true? a. Urgent or emergency care without aerosols is considered low risk. b. Aerosol-generating procedures on patients who are well are considered moderate risk. c. Procedures that do not generate aerosols are considered high risk on patients with COVID-19. d. All of the above are true

professional impact C D A J O U R N A L , V O L 5 0 , Nº 2

Impact of COVID-19 on Dentistry Anders Bjork, MBA

AUTHOR Anders Bjork, MBA, is vice president of strategic intelligence and analytics for the California Dental Association. In this role, he performs a variety of primary and secondary quantitative and qualitative research projects to help inform CDA’s leadership in decisions regarding the organization’s strategy. Conflict of Interest Disclosure: None reported.

any superlatives have been used to describe the global impact of COVID-19.1 Suffice it to say that probably no entity was able to avoid at least some impact from the pandemic; and of course for many, it has fundamentally and permanently changed their lives and businesses. The ongoing economic impact of COVID-19 will undoubtedly be felt for years — if not decades — to come. Some types of businesses benefited during this time, perhaps from unexpected demand for their products or a unique distribution feature that was deemed safer during the pandemic versus traditional offerings.2 However, the vast majority of companies that depend on direct interaction with customers suffered tremendous and longlasting economic damage. Health care was especially impacted for obvious reasons; most care is provided personally, clinician to patient, and many patient-provider care interactions increase the possibility of viral transmission. As experts began to evaluate the transmission mechanism of the COVID-19 virus, an early focus was to determine which medical procedures and disciplines had higher risk factors so as to be able to advise clinicians and their patients as to what nonemergent care could still be provided during the pandemic. As virologists studied SARSCoV-2, they determined that the spread was principally through aerosolized droplets emitted by an infected person’s respiration, coughing, sneezing and/ or touch.3 Therefore, much of the focus

of risk categorization then turned to an understanding and mitigation of risk in understanding aerosol-generating procedures.4 Those involved in dentistry and the support of the dental profession immediately understood that the impacts to patient care would be high given the frequent and widespread use of dental equipment known to create aerosols in the dental practice including but not limited to ultrasonic scalers, high-speed dental handpieces, air/water syringes, air polishing and air abrasion.5 The subsequent focus was to understand what personal protective equipment (PPE) could be used to allow patient care to continue while minimizing risk of transmission between staff and patients.6 For dentists, understanding how to safely treat patients during the pandemic — and indeed have patients feel safe about getting routine care — was the highest priority to address.

Economic Impacts

As the timeline of COVID-19-related events covered elsewhere in this issue describes, the guidance given to dentists by the American Dental Association (ADA) in mid-March 2020 was to postpone elective dental procedures and only see emergency patients.7 The ADA’s guidance was based on and developed from information from the Centers for Disease Control and Prevention (CDC) evidence-based recommendations.8 Similarly, on March 19, the California Department of Public Health (CDPH) expanded the shelter-in-place order for FEBRUARY 2 0 2 2

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18.9%

17.6%

17.2%

76.0%

79.5%

79.4%

12.7% 56.5%

6.9%

2.8% 7.1%

1.2% 2.1%

1.5% 1.3%

28.5% 62.9%

55.5%

Closed but seeing emergency patients

70.4%

53.9%

41.7% 33.8%

27.9% 10.8%

Week of April 6

Week of April 20

Week of May 4

Week of May 18

Open but lower patient volume Open and business as usual

Week of June 29

2.9%

Week of June 15

3.3% 0.1%

Week of June 1

2.8% 0.1%

Week of March 23

19.7%

4.9% 0.2%

Closed and not seeing any patients

FIGURE 1. Dentists’ self-reported practice status during first three months of the pandemic in 2020. (Source: ADA Health Policy Institute.)

California residents and directed that dentists should not schedule patients for nonemergency care until the order was lifted.9 CDA joined with the recommendations of the CDC, the ADA and the CDPH and urged all members to only treat emergency patients at that time. A week after issuing that guidance, the ADA’s Health Policy Institute (HPI) surveyed and found that almost 95% of dental practices had complied with that recommendation. Two weeks later, during the week of April 6, the ADA’s HPI found that more than 97% of dental practices surveyed across the country were either closed and seeing emergency patients only (79.5%) or fully closed and not treating any patients (17.6%)9 (FIGURE 1 ). Within a month, dental practices began to address some of the challenges and issues associated with treating patients during the pandemic, and dental practices began to make steady gains toward seeing patients at least on an emergent basis but also resuming routine care to the extent safely possible. Two principal factors limited patient care at this point in the pandemic: PPE (both the availability and confusion over the standards) and patient willingness/uncertainty 104

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about whether receiving dental care as a patient was safe at that time. Trying to determine the precise economic cost to the profession of dentistry is difficult, but we can begin to get some perspective using the U.S. Department of Commerce Bureau of Economic Analysis (BEA) 2019 data10 (TA BLE 1 ). 2019 provides a good baseline from which to measure the impact of COVID-19 on dental practices. For simplicity’s sake, this analysis makes several assumptions: ■ Expenditures are spread evenly through the year or approximately $11.23 billion dollars are spent on dental services each month. ■ Over the prior seven years, dental services grew at a compound annual growth rate of 3.33%, so without the pandemic, it is assumed that dental services would have increased by this amount and been worth $139.3 billion in 2020 or $11.61 billion per month (TA BLE 2 ). Compared to the expected growth in dentistry in 2020, it is estimated that the sector lost approximately 33.4% of revenue. Even if there was no growth in 2020 (using the 2019

dental services value), the dental sector lost approximately 31.1%. The ADA’s HPI also performed an economic analysis of the impact of COVID-19 on dentistry focusing on dentist net earnings. The HPI’s conclusion was that general practitioner dentists saw an average 17.9% drop in net income in 2020 compared to 2019.11

PPE

Dentists are accustomed to the routine use of PPE in the dental practice. As the COVID-19 pandemic hit, many were quick to point out that dentistry had to adjust to the realities of the AIDS/ HIV epidemic that struck in the early 1980s and could apply learnings from that experience. Given the frequency of bloodborne pathogen contact in dentistry, it was vital that dentists adjust their PPE practices to avoid exposure.12 The first challenge was to obtain clear guidance from a credible source as to what PPE protocols should be adopted.13 Understandably, as researchers were working to determine the method and severity of transmission for the SARSCoV-2 virus, there was initially much confusion over the proper level of PPE, to whom it should apply within a dental practice and even which governing entity (local, state, federal) should be issuing that recommendation. The CDC,5 the Occupational Safety and Health Administration (OSHA),14 the CDPH15 and the California Department of Health Care Services (DHCS)16 all issued infection control and PPE guidance, which was subsequently used by CDA to provide guidance for dental practices.17 Many practices undertook even more conservative methods of infection control, such as making physical modifications to their practices, including adding physical barriers to protect patients and staff (e.g., plexiglass

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TABLE 1

U.S. Bureau of Economic Analysis Data Showing Dental Service Expenditures 2012-2019 Year

2012

2013

2014

2015

2016

2017

2018

2019

Dental services, billions USD

$107.20

$108.60

$111.60

$116.30

$122.20

$126.60

$131.80

$134.80

TABLE 2

ADA HPI Dentist Survey Results Combined With U.S. BEA Data To Estimate the Financial Impact of COVID-19 on Dentistry Month

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

% of normal patient volume

100%

18%

45%

67%

72%

77%

80%

79%

76%

78%

Sector revenue

$11.61

$0.81

$2.09

$5.22

$7.78

$8.36

$8.94

$9.29

$9.17

$8.82

$9.06

$92.76

$ loss

$10.80

$9.52

$6.39

$3.83

$3.25

$2.67

$2.32

$2.44

$2.79

$2.55

$46.56

% loss

separating work spaces and/or reception areas), special ventilation equipment and implementing numerous patient protocols such as having patients wait in their vehicles prior to treatment to avoid risking contamination in the waiting room. However, having experience using PPE and an understanding of PPE protocols proved to be only part of the problem for multiple sectors reliant upon PPE for their work. As the pandemic had a broad global impact on manufacturing and supply chain logistics, even being able to acquire the desired PPE equipment became a challenge. Numerous factors contributed to the situation including a demand shock triggered by an acute need in health care and a panicked marketplace buying behavior that depleted domestic PPE inventories. There were even instances of PPE hoarding by speculators looking for arbitrage opportunities.18 The lack of effective action on the part of the federal government to maintain and distribute domestic inventories as well as severe disruptions to the PPE global supply chain amplified the problem. Analysis of trade data shows that the U.S. is the world’s largest importer of face masks, eye protection and medical gloves, making it highly vulnerable to disruptions in exports of medical supplies.19 The global supply chain had become accustomed to the practice of “Just-in-Time” (JIT) manufacturing inventory control, which has the desirable feature of minimizing

Total

33.4%

standing inventories and therefore the costs associated with them.20,21 Governments and large corporations were able to disproportionately influence supply chain activities, oftentimes leaving smaller entities unable to compete financially directly (the rising cost of supplies) or indirectly (existing or future partnerships of strong economic value). At particular disadvantage were small businesses without excess resources and/or influence on supply channels — like many dental offices.

Employment

As the COVID-19 pandemic commenced, most businesses began an immediate triage of what impacts they would need to account for as many employers realized that they would need to drastically reevaluate the way they provide their services in a pandemic economy. Hit particularly hard were employers in the service sector, notably restaurants, hotels and travel as normal behaviors and activities quickly ground to a halt (FIGURE 2 ). As demonstrated earlier in this article, almost all dental offices closed for at least some period of time early in the pandemic as they awaited more information about how the COVID-19 virus was transmitted and therefore clearer guidance on how to safely treat patients (and for patients to feel comfortable returning to the dentist). During the first weeks of closure, dental practices also struggled

with employment decisions, especially in light of confusing information about government grants and loans.22 Dentist employers grappled with whether to lay off employees, furlough them or retain them as employees but with reduced pay. As practices began to return to work through April and May, employers were met with a new set of challenges: How to bring their employees back to work amid competing priorities. As many schools began having their students participate in classes virtually, this created a challenge for parents’ ability to leave their homes for work. Many professional jobs were transitioned to remote work, but of course very few aspects of dentistry can be provided with clinicians working from home, so parents working with children learning at home needed to make a decision as to whether they could leave their children to participate in school unsupervised. The younger the children, the more difficult this decision became. And for the youngest children who were not yet in school, the impact was even more severe, as many day care centers were forced to close due to the risks associated with spreading the virus in those settings.23 Another factor at play was whether employees felt safe to return to work for fear of contracting COVID-19.24 This is especially relevant for dental practice employees, where the workplace environment could provide many potential exposures. Dental FEBRUARY 2 0 2 1

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Data in thousands -4,000

-3,500

-3,000

-2,500

-2,000

-1,500

-1,000

-500

0 Accommodation & Food Services, SA Health Care & Social Assistance, SA Admin & Support & Waste Services, SA Retail, SA Local Government, SA Arts, Entertainment and Recreation, SA Manufacturing, SA Other Services, SA Transport, Warehousing & Utilities, SA Construction, SA Professional, Scientific & Tech Services, SA Educational Services, SA Wholesale, SA Information, SA State Government, SA Real Estate & Rental & Leasing, SA Management of Companies & Enterprises, SA Mining & Logging, SA Finance & Insurance, SA Federal Government, SA

FIGURE 2 . U.S. Bureau of Labor Statistics data showing job change by industry from February 2020 to June 2020. (Source: U.S. Bureau of Labor Statistics.)

hygienists and dental assistants work very closely with patients’ mouths and therefore have a high probability of exposure to patient illnesses. The complications with PPE availability were also influencing behavior, as it was well-documented that having enough proper PPE was challenging in the earliest months of the pandemic.25 Lastly, employees who had been furloughed or were laid off were now eligible to receive enhanced unemployment benefits offered by the government to help alleviate financial hardships created by the pandemic. For some members of the dental team, the value of these benefits potentially influenced some behaviors around whether to return to work or not (although this is difficult to prove because admission of that as a reason would be reason to terminate those same unemployment benefits). One study found that the enhanced unemployment insurance (UI) benefit supplement allowed 37% of the workforce to earn more with UI benefits than from working.26 106

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As dental offices returned to work, the employment situation created a circular problem: Many offices were unable to maintain full patient schedules due to pandemic-related infection control protocols and therefore couldn’t hire back all of their staff. At the same time, having full staffing would allow the practices to generate enough practice revenue to hire back their staff. Without a clear understanding of how the pandemic would play out, many dentists faced difficult decisions on staffing (FIGURE 3 ).

Nonowner Dentists

As offices returned to work through the pandemic, among the hardest hit were nonowner dentists working as associates, employed and/or contract employees in dental practices. Several probable factors explain this trend. As previously discussed, as dental practices initially responded to the pandemic, it was commonplace for offices to furlough or terminate most or all of their employees even if only for a few weeks while determining how to proceed. Also as previously covered, as

practices came back online, they were not able to see their full, normal, prepandemic volume of patients. So owner doctors — with their own income on the line — resumed their roles as the primary provider in the practice. This makes sense; owners typically hire associates to increase their volume either from a supply or demand standpoint. Unfortunately, associate dentists tend to be younger, often near the start of their careers and looking to gain experience, skill and procedural speed. Because of their relative newness to the profession, they are therefore more likely to be working to service substantial levels of educational debt, with their creditworthiness and debt service based on full employment in their chosen profession of dentistry. Yet through most of the pandemic, approximately one-quarter of associates were unable to work due to lack of demand for their services. Even as practices continued to increase their patient loads, the return to work for employed dentists stagnated. As dental offices worked through the summer surge of returning

C D A J O U R N A L , V O L 5 0 , Nº 2

Employment as a percentage of January 2020 employment, by health care industry 120

Percentage

100

Offices of dentists, 99.8 89.2

Offices of physicians, 98.2

80 76.0

Offices of other health practitioners, 95.4

44.2

40 20 0

2020 2020 2020 2020 2020 2020 2020 2020 2020 2020 2020 2020 2021 2021 2021 2021 2021 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY

FIGURE 3 . National employment data indicating impact of COVID-19 on selected health employees. (Source: U.S. Department of Labor, Bureau of Labor Statistics, Current Employment Statistic.)

patients, that volume began to dwindle into the fall, further exacerbating the plight of associates (FIGURE 4 ). The pandemic employment situation definitely affected the concerns of dentists with loans. Survey work done by the ADA’s HPI shows how poll respondents felt the pandemic contributed to their financial stress (FIGURE 5 ). Fortunately, part of the overall federal relief package did specifically address the student loan situation. The U.S. Department of Education provided a suspension of loan payments, 0% interest rate and cessation of collection on defaulted loans.27 It is too soon to know what the longer-term impacts to these associates will be. Some may have relocated to any place they could find jobs. It is also possible that there may be impacts on debt service for these dentists, especially if they were not able to secure government subsidies to offset their losses. Whether there could be a longer-term impact on the creditworthiness of dental students in general remains to be seen.

Patient and Staff Hesitancy

The issue of vaccine hesitancy has been covered extensively by news organizations. The focus of discussion here will be patient hesitancy in returning to the dentist and staff hesitancy in returning to work in the dental practice. In the first weeks of the pandemic, there was frequent media coverage on what were considered safe and unsafe activities during the pandemic. Dentistry — along with routine/preventive medical care — was a common question and concern. To better understand patient concerns about visiting the dentist during COVID-19, CDA commissioned a research study to determine whether a media campaign to reinforce the importance and safety of visiting the dentist during the pandemic would be of benefit. The initial wave of the consumer survey was fielded June 15, 2020, to June 18, 2020, to establish a baseline measure, with a follow-on survey fielded Aug. 10, 2020, to Aug. 17, 2020, to measure change. There was initial concern that

patients were reluctant to return for dental procedures during COVID-19, but the baseline study indicated that patients were returning to their dental appointments at a greater rate than was expected. More than half the sample had been to the dentist within the past six months (three months of which were during the pandemic), and more than 10% of the sample had been within the past month. Most encouragingly, almost 8 in 10 respondents indicated that they planned to keep their scheduled/upcoming appointments. As the pandemic worsened through the summer of 2020, the followon research indicated that the population’s feelings about going to the dentist were stable. Again, slightly more than half the population had been to the dentist within the prior six months, and there was a significant increase among those who said they had been in the last month. There was also a slight increase in those signaling that they intended to keep their upcoming scheduled appointment with more than 8 in 10 respondents agreeing. FEBRUARY 2 0 2 1

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Pay status of nonowner dentists 100% 80% 60% 40% 20%

27 us t1 0 Au gu st 24 Se pt em be Se r pt em 7 be r2 1 O cto be r5 O cto be r1 N 9 ov em be N r ov em 2 be N r1 ov em 6 be r3 De 0 ce mb er 14

Not being paid at all

Au g

ly Ju

ne Ju

ay M

Yes, partially

Yes, fully

FIGURE 4 . Pay status of nonowner dentists (associates/contract employees working for another owner dentist). (Source: ADA Health Policy Institute.)

On a scale from 1 to 10, please rate the level of stress your student loan situation placed on you BEFORE the COVID-19 pandemic.

4.5 On a scale from 1 to 10, please rate the level of stress your student loan situation has placed on you personally NOW.

5.9 FIGURE 5 . ADA HPI data showing the effect of COVID-19 on dentists concerned with student loan situation, November 2020.

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These findings are consistent with other studies, specifically similar research that the ADA performed with Engagious, a consumer research firm, and its “Back to Normal Barometer,” which measures consumer sentiment across a broad range of economic activities.28 The ADA included several questions about returning to the dentist and saw similar results (FIGURE 6). Within CDA’s research, there were some interesting trends related to the geography of California. Notably, there were measurable differences in how consumers responded to whether they intended to keep their upcoming dental appointment. In urban and suburban areas, intention to keep an upcoming appointment increased, while in rural areas, it decreased slightly overall, with a very large drop in the northeast portion of California. The general demography of the area provides a plausible explanation: The population skews older (more susceptible to COVID-19) and more politically conservative (the pandemic became increasingly politicized as 2020 progressed29), and some notable nursing home incidents related to COVID-19

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Assuming you had the necessary assurances that it was safe to resume normal activities, how quickly would you next visit a dentist’s office? outbreaks were newsworthy locally in Northern California, to which this population could relate30 (FIGURE 7 ). The study provided additional findings regarding communication and expected patient behavior. With regard to communications, the survey tested several potential messages around dental offices and infection control protocols to determine what resonated most positively with patients. With media focus on PPE, it was not surprising to learn that patients wanted to know that dentists and their staff were using PPE. The survey also found that confirmation of routine dental office staff testing for COVID-19 and reminding the public that dentists have always had strict infection control protocols and routinely disinfect their work areas were important (FIGURE 8). In the second wave of the research, the respondent sample was split to measure contrasting response on one question, with half the recipients asked what their response to keeping their upcoming appointment would be if they learned that someone at the practice was exposed. About a third of those respondents indicated that they would cancel their appointment. However, the other half of the sample received additional information about the exposed practice employee. Specifically, that extensive safety protocols were being employed to quarantine that employee at home, test other employees who might have been exposed and thoroughly disinfect workstations between all patients. This additional messaging decreased the cancel rate by almost 50%, indicating the importance of proactively managing not only messaging but also any incidence of COVID-19 exposure in the practice (FIGURE 9 ). The last important finding from the research is consistent with several other studies regarding consumer sentiment during the time of COVID-19. With

More than a year out 2% Within six months to a year 6%

Immediately 45%

Within three to six months 10%

Within three months 10% Within one month 17%

Within two months 10% n= 289, Back to Normal Barometer, July 22, 2020

FIGURE 6 . ADA/Engagious research results showing that 82% of patients intend to visit their dentist within three months.

Urban 48% – >50% Northern CA -16 to 40% N=92

Suburban 43% – >50% +7 (stat. sig.) Small town/Rural 48% – >47%

Central Coast +26 to 68% N+50

Southern CA (as a whole) +6 to 51% N=702

Orange County +11 to 63% N=95

FIGURE 7. Geographic changes among those who said they would ”definitely” keep an upcoming dental appointment. (Survey fielded Aug.10-17, 2020. Source: CDA/EDGE Research.) FEBRUARY 2 0 2 2

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Very convincing top 3 for each in bold

Reasons to feel comfortable going to the dentist 79% 77%

Dental workers wearing PPE (i.e., masks, gloves, etc.)

WAVE 2 WAVE 1

Confirmation that staff is routinely tested for COVID-19

WAVE 2 WAVE 1

Learning dentists have always had strictest infection control protocols of any medical profession

WAVE 2

42%

Hearing from your dentist about safety precautions, such as cleaning and disinfecting all surfaces before each exam and sterilizing equipment between patients

WAVE 2 WAVE 1

41% 43%

75% 76%

Hearing from your dentist about specific safety precautions in place at their office to minimize interactions between patients, such as staggering visits and limiting the number of people in the waiting room

WAVE 2 WAVE 1

41% 40%

73% 74%

Hearing that your dentist has specific rules for employees who may have been exposed to COVID-19

WAVE 2

39%

Confirmation your dentist is not treating COVID-19 patients

WAVE 2 WAVE 1

39% 41%

Medical experts saying it’s safe to have routine dental procedures

WAVE 2 WAVE 1

48% 49%

78% 75%

44% 45%

76%

72% 70% 68% 66% 65%

32% 34%

Very convincing

Comfortable Likely and returning but anxious

Anxious and waiting

69%

47%

23%

56%

45%

24%

60%

41%

20%

60%

42%

16%

59%

39%

19%

59%

36%

18%

52%

38%

21%

50%

27%

13%

Somewhat convincing

FIGURE 8 . Testing statements that reassure patients about dental practice safety during COVID-19. (Survey fielded June 15-18, 2020, for wave1 and Aug.10-17, 2020, for wave 2. Source: CDA/EDGE Research.)

If found out dental staff at practice was exposed?* Definitely keep appt Probably keep appt

35%

Cancel

30%

24%

40%

Delay appt Cancel Not sure/ it depends

Comfortable Likely and returning but anxious

16%

Probably keep appt

16%

Delay appt

Not sure/ it depends

Definitely keep appt

15%

Difference with more information

If found out dental staff was exposed and extensive protocols used?**

18%

Anxious and waiting

-1

+12

-8

+24

-3

-13

-26

*Q19A: Imagine you have a dentist appointment coming up and you find out that someone at your dentist’s practice has been exposed to COVID-19. Which of the following best describes how this might impact your plans for your upcoming appointment? **Q19B: Imagine you have a dentist appointment coming up and you find out that someone at your dentist’s practice has been exposed to COVID-19. They let you know that any dentists and employees who have had close contact with the person who tested positive are not coming into work and will remain at home for at least 10 days or until any symptoms that may appear have gotten better. In addition, they explain their office disinfection procedures and that their ventilation system is designed to reduce/eliminate the spread of germs between different areas of the office and exam rooms. Which of the following describes how this might impact your plans for your upcoming appointment? FIGURE 9. Impact of information in the event of exposure reduces cancellation rate. (Survey fielded Aug.10-17, 2020. Source: CDA/EDGE Research.)

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Change in feelings about going to the dentist during COVID-19

Plan to visit when due for regular care/cleaning

72%

45%

are likely to show up when due for regular care/cleaning

50%

43%

WAVE 1

Feel more negatively

37%

WAVE 2

Definitely visit

24% 23%

10%

Probably visit

Within 9 months

Within 1 year

More than When vaccine 1 year available

Much more positive

33% 33%

Somewhat more positive

47%

13% 14%

No change

Somewhat more negative

Much more negative

Only 1 person mentioned WHO when asked why.

Concern index: Plan to visit and feelings about going to the dentist 27% 26%

22%

20%

19% 20%

12% 12%

Comfortable and returning 35%

Likely to return but anxious 39%

Anxious and waiting 26%

FIGURE 10 . No significant changes through the course of the research with regard to patient sentiment. (Survey fielded Aug.10-17, 2020. Source: CDA/EDGE Research.)

regard to returning to the dentist during COVID-19, the population seems to divide into categories of those who are generally unconcerned, those who will return but are anxious about it and those who are anxious enough to avoid returning until they are sure it is safe to do so (generally defined as having an approved vaccine) (FIGURE 10 ). Again, the ADA’s research with Engagious showed a directionally similar result with regard to patient sentiment on COVID-19 exposure in a dentist’s office and willingness to return (FIGURE 11 ).

Speculated Impacts to Dentistry Permanent Adoption of Increased Patient and Staff Safety Protocols

As has been presented previously, all practices adopted new safety protocols to mitigate the risk of viral transmission to

and from the dentist, the staff and the patient. Many practices took measures beyond PPE and included physical and technological modifications to their practices. Some of the more advanced modifications to practices were possible during the period the practice was closed in the first weeks of the pandemic, as the work could be done without impact to patient care. For dentists with foresight, stimulus grants and loan funds, empty offices and contractors looking for work combined to create an opportunity to make these modifications. These changes are likely to become permanent for several reasons. For anything beyond PPE, these changes can often represent capital investments in the practice, and leaving them in place has financial/tax advantages to the practice. Furthermore, most scientists agree that

we are unfortunately likely to see more pandemics in the future.31–35 As such, dentists who made the investments in these technologies and trained their staff to work with high levels of respiratory protection will not only be safer from less harmful illnesses in the near term, but they will also be better prepared to serve patients without disruption in the future event of another pandemic. In the meantime, these physical modifications are easily visible to nervous patients who may be reassured by their dentist’s proactive attention to their safety. Also, as removing many of these physical modifications would impact patient care, dentists would likely be reluctant to disrupt their schedules long enough to remove them, especially if paying a contractor to do so would be required. FEBRUARY 2 0 2 1

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Let’s assume that you become aware of a situation where someone in your area was confirmed to have contracted COVID-19 from a visit to a dental office where you were not personally a patient. Which of the following best reflects your willingness to visit the dentist? I would be fine visiting my own dentist with the assurance from the dentist’s office that they were using enhanced safety protocols related to COVID-19 in accordance with CDC and ADA guidelines

I would be fine visiting my own dentist without hesitation or additional assurances

15%

36%

I would not be comfortable visiting my own dentist unless there was an approved COVID-19 vaccine and/or a proven medical protocol to mitigate and remedy the effects of the virus

I would be willing to visit my own dentist as long as a combination of state and local or national medical authorities, local or national government officials and/or the location I am visiting provided assurances that it is safe to do so

24%

25% N = 598, Back to Normal Barometer, July 8, 2020 FIGURE 11. ADA/Engagious data showing that local COVID-19 cases would not impede patient visits.

General Practice Dentists and Specialists

During the 2008-2011 recession, there was an observable trend toward general practice (GP) dentists referring less work outside of their practices, preferring to keep that work in-house for revenue reasons, but also to increase their own clinical skill and retain their patients.36 It is reasonable to expect that this trend will continue following COVID-19, as many GPs seek to recover losses incurred during the pandemic. However, several specialties will likely be less affected. Pediatric dentistry will progress with less impact as parents — especially those with means — continue to spend on their children’s health. Periodontists, oral surgeons and endodontists may find an increase in patient needs due to delayed preventive and routine care. And similarly for orthodontists with clear aligners, technology will assist these specialists in offering new and less-invasive methods of treatment for 112

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patients (although the digital nature of design in clear aligners also benefits GPs). An unexpected side effect of the virtual work environment was people’s sudden awareness of their teeth and smiles as so many employees were relegated to having their heads appear in a box on a screen. This has been dubbed “Zoom dysmorphia” or more simply “The Zoom Effect.”37 That, combined with increased discretionary funds from a lack of ability to travel, created a situation that drove unexpected demand for clear aligner treatments.38

Dental Support Organizations (DSOs)

DSOs continue to grow their share of patient care through economies of scale and active marketing/recruitment practices to new dentists seeking employment. The ADA’s HPI polling data through the pandemic showed that DSOs were somewhat slower to recover versus private practices, likely due to their reliance upon associate/employed dentists

who were more likely to be furloughed or laid off at the start of the pandemic and perhaps seek other practice settings. DSOs are also oftentimes reliant upon venture capital (VC) and private equity (PE) investors for capital infusions. Depending on how those investing entities have diversified their holdings, it is possible that some may find themselves overleveraged through the pandemic and find the need to liquidate some assets. It is unclear if dental holdings might be impacted or to what extent. To that end, it is plausible that there might be more consolidation in the profession, as smaller DSOs seek to “roll up” to larger DSOs as an exit strategy, and that some PE/VC firms may seek to sell their dental interests as they adjust their portfolios in a post-pandemic economy. This could have the effect of reducing the flow of capital into this practice model, which would in turn likely curtail some of the growth in this care segment.

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Medical/Dental Integration

Although society accepts without question that visits to a physician and a dentist are handled quite differently, not much recognition is given to why this is the case and the history that created the separation that still exists today.39 Patients see physicians for all medical needs through more complex health system structures, medical groups and physician organizations, often booking their appointments through centralized call centers and/or app-based/ online appointment systems. Physician encounters are also oftentimes paid for through true risk-based medical insurance. However, when it comes to teeth, patients typically call their local dentist’s office and make the appointment with a live individual working in that office. And the payment for treatment might be fully or partially covered through a dental benefits plan, which is quite dissimilar to health insurance and better described as a savings plan with negotiated provider discounts. Again, we accept that this one feature of our anatomy/health should be carved out and handled differently with regard to care and payment. With greater focus on integrated health and systemic approaches to care, there are increasing discussions and focus on whether this separation still makes clinical sense for the patient.40 Some influential health care entities such as Kaiser Permanente — which integrates dental care into their business model in the Pacific Northwest — are no doubt discussing whether there is a patient case to combine these disciplines on a broader scale across their substantial national footprint.41 The COVID-19 pandemic has cast more positive light on the role of dentistry in the health care continuum. Dentist and physician needs for PPE, infection protocols and patient safety have all combined to create more of an acceptance of dentists as “essential health

care providers,” a phrase frequently heard through the pandemic. Unfortunately, a reduction in patient flow to dental offices and the resulting reduction in profitability may also contribute to exploration of and innovation with new partnerships and care delivery models that could achieve economic efficiencies.

Third-Party Payer Disruption

Prior to the pandemic, dental benefits plan reimbursements were a frequent source of concern for dentists. Even prepandemic, most participating providers

The COVID-19 pandemic has cast more positive light on the role of dentistry in the health care continuum.

cited that the payments strained their practices’ ability to cover the costs of providing care. Costs of providing care have increased through the pandemic, as requirements for PPE and the cost associated with acquiring it have increased dramatically.42 But dentists are often seeing fewer patients due to many of the factors discussed in this article: Increased duration between patients allows fewer patients to be seen versus prior to the pandemic; many offices cannot hire enough staff to see the patient volumes they experienced — and on which their practice economics were based — prior to the pandemic; and some offices are experiencing patient relocations for their own jobs, often voluntary but far enough away to disrupt the patient relationship. The combined effect is that practices are working harder

to see fewer patients and cannot spread the financial risk of dental benefits plans across the same number of patients as they previously did before the pandemic. A reimbursement that may have been 60% to 80% of the dentist’s actual charges before the pandemic might be less than the overhead cost of providing care now. This is causing providers to take a critical look at the economics of benefit plans and determine if they can indeed afford to continue accepting them. It seems unlikely that benefit plans would increase their reimbursement levels without some financial incentive or necessity to do so. A more integrated approach to health care as described previously could also shift the payment mechanisms in dentistry, specifically if dental work could be covered through traditional risk-based health insurance plans.

Access to Care Issues

Government dental benefits through Medicaid (the Medi-Cal Dental Program in California) are generally perceived to offer lower reimbursements. As provider offices evaluate all their payer sources per the above, it is expected that there will be a greater exodus of offices accepting these plans. Dentists often cite their participation in government plans such as Medicaid as a societal and/or professional obligation to help care for populations that have limited access to care. When their practice success permits, many choose to take on additional un- and undercompensated care as a way to “give back.” Also, a focus on improved oral health can improve patients’ overall health and reduce costly care in other areas, giving dentists a compelling reason to help these patients live healthier — and potentially less expensive — lives. Many accept the losses in this area with the intention of recouping those losses through higher commercial payments FEBRUARY 2 0 2 2

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Has your practice disenrolled from Medicaid since the onset of the COVID-19 pandemic? Overall

California

94%

99%

Is your practice considering disenrolling from Medicaid in the coming months? Overall

California

16%

21%

63%

20%

76%

Yes

Not sure

FIGURE 12 . ADA HPI polling data among Medicaid dentists, August 2020.

and/or cash-paying patients and/or they chalk up the losses to obligatory participation in the care continuum. However, overall increases in practice costs may prove this model is no longer feasible. Indeed, the ADA’s HPI polling shows more practices disenrolling from these programs through the pandemic. When the ADA’s HPI initially asked this question of their poll participants, 6% nationally had already disenrolled in the pandemic and another 16% were planning to disenroll from Medicaid. In California, where CDA has successfully advocated for Medi-Cal reimbursements for dentists through Proposition 56, the likelihood of disenrolling from the program is much lower: Only 1% had already disenrolled with 4% planning to disenroll. A future ADA HPI poll on this subject found that 20% of respondents also said their ability to accept Medicaid patients had decreased during the pandemic. These data taken together indicate a likely reduction in care capacity and therefore access in the near future (FIGURE 12 ). 114

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Retirement and Turnover

Dentists over the age of 60, and especially those over 65, will likely be weighing the effort of recovering from the pandemic against the cost of winding up their careers. Those who suffered through the last economic downturn may not have the energy — or time left in their careers — to do it again. The ADA’s HPI polling data do indicate an increasing number of later-career dentists considering their options of selling or closing and retiring43 (FIGURE 13 ). On the positive side, there have not been great opportunities for younger dentists to buy private practices over the past five to seven years. Strong economic recovery after the last downturn has kept many older dentists practicing, likely to offset losses they incurred during said downturn. However, younger dentists have struggled to find practices available for sale and experienced more competition for those practices especially in desirable living areas. This situation could provide some balance in practice

transfers, although dentist-buyers will be competing with each other and also with cash from VC and PE firms.

Longer-Term Workforce Challenges

Although the workforce issue was discussed previously in this article, as the pandemic wears on, it has become increasingly apparent that the dental profession — among many others — has not seen a full recovery and it may take some period of time to achieve that. The ADA’s HPI has continued to survey member-dentists on their staffing challenges, and they report that the problem has actually been somewhat exacerbated through the pandemic. Dentists are facing even greater challenges in recruiting dental team members than they were in October 2020. About 4 in 10 have recently or are currently seeking dental assistants and roughly one-third have recently or are currently hiring dental hygienists.44 Among those recruiting, 90% considered recruitment of dental

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Downsize dental team

22.0%

Reduce dental team hours

78.0% 38.4%

Reduce employee wages, benefits

61.6%

13.4%

86.6%

Disenroll from dental benefits plans

21.3%

78.7%

Change supplier, dental lab

20.9%

79.1%

Raise fees

58.7%

Borrow money from a bank

18.8%

Sell my practice Join a DSO or large group practice

81.2% 36.1%

7.3%

63.9% 92.7%

Retire Other, specify

41.3%

38.5%

61.5% 93.8%

4.3%

Yes

FIGURE 13. ADA HPI poll data showing what measures respondents aged 65 and over would consider if patient volumes continue at current levels (Nov. 24, 2020).

hygienists extremely or very challenging.44 Open staff positions are the most common limiting factor for practices that want to see more patients (FIGURE 14 ). It seems that the tail of the COVID-19 pandemic may be long when it comes to employment and workforce recovery. The portion of the population that has become solidified in their resistance to getting vaccinated has contributed to the spread of COVID-19 variants in the population, especially the delta variant. Vaccineresistant people often cite that vaccinated individuals can still transmit the virus and can in some cases still become sick from COVID-19. Their contention is that the vaccine seems pointless in this regard. However, as many individual employers take increasingly stronger stances on requiring proof of vaccine to remain employed,45,46 this will of course have the unintended consequence of shrinking the overall employment pool. The U.S. Census Bureau finds that approximately 3 million adults are not working due to concerns about “getting or spreading the coronavirus.”26 This portion of the population may not feel comfortable returning to the workforce until the virus

24%

29%

32%

Dental hygienist October 2020

32%

May 2021

36%

August 2021

39%

Dental assistant October 2020

May 2021

August 2021

FIGURE 14. Percentage of owner dentists recently or currently recruiting by position. (Source: ADA Health Policy Institute’s COVID-19 Economic Impact on Dental Practices Poll.)

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Week of March 23 Week of April 20 Week of May 18

76.0%

3.3%

79.4%

10.8%

Week of June 15

18.9% 17.2%

53.9%

28.5%

33.8% 41.6%

Week of July 13

56.3%

48.8%

Week of Aug 24 Week of Sept 21

49.9%

46.8%

52.4%

39.4%

Week of Oct 19

59.3%

32.8%

Week of Nov 16

65.6%

38.5%

Week of Dec 14

60.3%

42.6%

Week of Jan 18 Week of Feb 15

56.2%

42.6%

Week of March 15

55.5% 50.8%

48.5%

58.1%

Week of April 12

6.9%

62.9%

41.5%

60.9%

Week of May 17

38.4%

64.6%

Week of June 14

34.7%

67.7%

Week of July 12

31.4%

64.8%

Week of Aug 16

34.1%

62.1%

Week of Sept 13

37.3%

Open and business as usual

Closed but seeing emergency patients only

Open but lower patient volume than usual

Closed and not seeing any patients

FIGURE 15 . ADA HPI poll data indicating practice status as of Sept. 13, 2021.

has been all but eradicated, if that is even possible. Some health researchers are beginning to introduce the concept of the endemicity of COVID-19, which means that the virus would become another illness to be treated like a flu or other routine illness.47 These factors combine to create a complicated employment situation. Through the summer of 2021, there were a record nearly 10 million job openings in the labor market.26 For dentistry, where most work cannot be conducted remotely and there is a high probability of exposure, this may have the ultimate effect of changing the dental office employment structure in some way that has yet to be seen. Some researchers expect that the pandemic will foster an environment of greater workplace automation.26 Prior research has shown that workplace automation increases 116

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following recessions as employers choose to invest in new technology instead of rehiring workers.26 It might be difficult to create more automation within dental offices, but a McKinsey study projects that 73% of activities in accommodation and food service industries could be automated.48 This could have the indirect effect of transitioning those displaced employees into new occupations and could create a pool of potential dental office support employees.

Conclusions

Throughout this article, COVID-19related impacts to the dental profession have been presented. The pandemic was (and remains in many regards) clearly a tumultuous time for any business, sometimes increasing demand and improving revenue (with challenges), but

oftentimes having a more negative effect as is noted in the profession of dentistry. As the pandemic began, it was unclear how long it would last and how long dental practices would be unable to see patients or to see patients at a reduced capacity. With the benefit of hindsight, it appears that the recovery curve was shorter and steeper than expected; truly, many practices were closed for a few weeks to a month at most before mounting an encouraging comeback.49 As depicted in FIGURE 1 , in the first weeks of April 2020, more than 97% of dental offices were completely closed or only seeing emergency patients. By the end of June, that same number — more than 97% — of dental offices were open and reporting business as usual or open with lower patient volume. Anecdotally, some offices reported having record patient volumes

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during June and so busy as to have to push patients into July and even August to be seen. However steep the curve, it does also appear that the tail will be long. Indeed, a year later, the needle moved barely 2% to just over 99% (FIGURE 15 ). As the pandemic began, some predicted that some practices might not be able to recover from the closure and will cease to operate. Although no formal research was done to support this, some speculated that the number of permanently closed practices could approach 10%. In fact, the number of offices closed during the pandemic generally hovered around 2%, and according to the ADA HPI data, a year later, the number remaining closed as a result of the pandemic nationally is less than 1%. Dentistry continues to emerge from the pandemic battered but recovering and getting back to work. Certainly, this was a learning experience for all involved, and dental offices will be better prepared for the next pandemic. Until then, dentists are taking this opportunity to refocus on patient care and their practices. n RE FEREN CE S 1. World Health Organization. Naming the coronavirus disease (COVID-19) and the virus that causes it. 2. Arora R. Which companies did well during the pandemic. Forbes June 30, 2020. 3. Centers for Disease Control and Prevention. How COVID-19 spreads. 4. Klompas M, Baker M, Rhee C. What is an aerosolgenerating procedure. JAMA Surg 2021;156(2):113–114. doi:10.1001/jamasurg.2020.6643. 5. Centers for Disease Control and Prevention. COVID-19. Guidance for dental settings. 6. Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic. 7. Burger D. ADA recommending dentists postpone elective procedures. ADA News March 16, 2020. 8. Centers for Disease Control and Prevention. Guidance for dental settings during COVID-19 response. 9. American Dental Association. Economic impact of COVID-19 on dental practices. 10. Bureau of Economic Analysis. National income and product accounts. 11. Munson B, Vujicic M, Harrison B, Morrissey R. How did the

COVID-19 pandemic affect dentist earnings. American Dental Association Health Policy Institute 2021. 12. Silverman Jr. S. The impact of HIV and AIDS on dentistry in the next decade. J Calif Dent Assoc 1996 Jan;24(1):53–5. 13. California Dental Association. COVID-19 information and FAQs. 14. Occupational Safety and Health Administration. Dentistry workers and employers. 15. California Department of Public Health. Guidance for resuming deferred and preventive dental care. 16. Department of Health Care Services. Information on the novel coronavirus (COVID-19) for Medi-Cal Dental providers. 17. California Dental Association. PPE recommendations for dental practices. 18. World Health Organization. Shortage of personal protective equipment endangering health workers worldwide. 19. Cohen J, van der Meulen Rodgers Y. Contributing factors to personal protective equipment shortages during the COVID-19 pandemic. Prev Med 2020 Dec;141:106263. doi: 10.1016/j.ypmed.2020.106263. Epub 2020 Oct 2. PMCID: PMC7531934. 20. Goodman PS, Chokshi N. How the world ran out of everything. The New York Times June 1, 2021, updated Oct. 22, 2021. 21. Hadwick A. The end of just-in-time? Reuters Events July 3, 2020. 22. California Dental Association. Layoffs, furloughs and wage reductions: Considerations for dental practice owners heading into 2021. 23. Leonhardt M. Lack of school and child care could mean losing ‘a generation of working parents.’ CNBC Aug. 6, 2020. 24. Carlisle M. Scared to return to work amid the COVID-19 pandemic? These federal laws could grant you some protections. Time May 6, 2020. 25. Holli. How dental professionals feel about returning to work. DirectDental May 20, 2020. 26. McGinnis K. Understanding the COVID-19 rise in longterm unemployment. Bipartisan Policy Center June 28, 2021. 27. Federal Student Aid. COVID-19 emergency relief and federal student aid. 28. Engagious. “Back-to-normal” key findings. 29. Sol Hart P, Chinn S, Soroka S. Politicization and polarization in COVID-19 news coverage. Sci Comm 2020 Oct;42(5):679–697. doi: 10.1177/1075547020950735. 30. Pohl J, Chen E. ‘They wanted to live.’ Inside a California nursing home as COVID-19 swept through its doors. Sacramento Bee July 11, 2020. 31. Klein A. This won’t be the last pandemic. Where will the next one come from? New Scientist June 17, 2020. 32. Sholts S. Why this pandemic won’t be the last. Smithsonian March 4, 2021. 33. Sridhar D. COVID won’t be the last pandemic. Will we be better prepared for the next one? The Guardian March 24, 2021. 34. McLaughlin K. WHO chief warns that COVID-19 won’t be the world’s last pandemic as he tells countries to prepare for future emergencies. Business Insider Dec. 27, 2020. 35. Gill V. Coronavirus: This is not the last pandemic. BBC News June 6, 2020. 36. Dykstra B. Think twice before referring profit out of the practice. Dental Economics Feb. 6, 2013. 37. Mechling L. Straightening your teeth is the latest pandemic

project. Shape Jan. 22, 2021. 38. Booth J. Pandemic-proof? Align Technology sold a record number of clear aligners in 2020. Dental Tribune Feb. 10, 2021. 39. Beck J. Why dentistry is separate from medicine. The Atlantic March 9, 2017. 40. Simon L. Overcoming historical separation between oral and general health care: Interprofessional collaboration for promoting health equity. AMA J Ethics 2016 Sep 1;18(9):941–9. doi: 10.1001/journalofethics.2016.18.9.pf or1-1609. 41. The medical/dental clinic. Repertoire May 2018. 42. Diaz D, Sands G, Alesci C. Protective equipment costs increase over 1,000% amid competition and surge in demand. CNN April 16, 2020. 43. Bomey N. Dentists could raise fees, exit family practices as pandemic keeps patients away. USA Today Oct 19, 2020. 44. American Dental Association Health Policy Institute. COVID-19: Economic impact on dental practices week of August 16 core results. 45. National Law Review. Class action trends report, fall 2021: The great vaccination dilemma. Oct. 2, 2021. 46. Smart T. As governments stumble, companies find a way to boost vaccine acceptance. U.S. News and World Report Oct. 5, 2021. 47. Feldscher K. What will it be like when COVID-19 becomes endemic? Harvard T.H. Chan School of Public Health News Aug. 11, 2021. 48.Manyika J, Chui M, Miremadi M, et al. A future that works: Automation, employment and productivity. McKinsey & Company 2017. 49. Kliff S. How’s the economy doing? Watch the dentists. The New York Times June 10, 2020. T HE AU T HOR , Anders Bjork, MBA, can be reached at anders.bjork@cda.org.

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Organized dentistry’s confidential, peer-to-peer wellness program CDA’s Wellness Program For dental professionals who suffer from alcohol or chemical dependency, the challenges of this past year may have profound impacts on health, personal relationships and practicing safely. Volunteer members and recovering dentists offer confidential peer-to-peer support, assistance finding facilities for evaluation or treatment and guidance for family members. Visit cda.org/Wellness-Program to learn more.

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protecting dhcp C D A J O U R N A L , V O L 5 0 , Nº 2

COVID-19 and Oral Health Care: Implications for Dental Practices Jayanth Kumar, DDS, MPH

abstract The coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges to dental health care personnel (DHCP). Because a large proportion of COVID-19 cases are asymptomatic and many dental procedures generate aerosols, additional precautions are needed to protect DHCP and their patients. Dental practices must comply with several state and federal requirements, including the California Department of Public Health Officer orders and California Division of Occupational Safety and Health (Cal/OSHA) standards. The California Dental Association has developed resources to assist dental professionals in complying with these requirements. In addition, the Medi-Cal Dental Program and local oral health programs have used various materials to educate the public about COVID-19 and oral health, including information for parents about visiting the dental office.

AUTHOR Jayanth Kumar, DDS, MPH, is the state dental director for the California Department of Public Health. Conflict of Interest Disclosure: None reported.

he rapid emergence of the coronavirus disease 2019 (COVID-19) into a pandemic has challenged dental health care personnel (DHCP) to achieve an unprecedented level of knowledge, skills and confidence for preventing transmission of the SARS-CoV-2 virus in the dental setting. Although dental practitioners know the minimum standards of infection control and take infection control courses every two years in California, these standards address bloodborne pathogens and not a respiratory virus. Because a large proportion of COVID-19 cases are asymptomatic and many dental procedures generate aerosols, additional precautions are needed to protect DHCP and their patients.1

Limited literacy is a potential barrier to effective prevention, diagnosis and treatment of oral disease.2 The adverse effect of limited oral health literacy on the utilization of dental services was exacerbated during the COVID-19 pandemic. In 2018, California published its 10-year state oral health plan.3 A key objective in the plan is to increase annual dental visit rates. It is aligned with one of the Healthy People 2030 leading indicators: To increase the proportion of children, adolescents and adults who use the oral health care system from 43% (the 2016 baseline) to 45% by 2030. To address this, the California Oral Health Plan 2018-2028 included a goal to develop and implement communication strategies to inform and educate the FEBRUARY 2 0 2 2

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TABLE 1

Timeline of COVID-19 Guidance and Protocols for Dentistry Date

Action

March 4, 2020

Executive Order N-33-20. State of Emergency declared in California

March 16, 2020

American Dental Association (ADA) recommends that dental practices postpone elective dental procedures until April 6, 2020

March 19, 2020

Stay Home Order of the State Public Health Officer issued in California

April 7, 2020

CDC COVID-19 Guidance for Dental Settings. Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response

April 9, 2020

CDA COVID-19 Clinical Care Workgroup convenes

May 7, 2020

CDPH issues Guidance for Resuming Deferred and Preventive Dental Care

Jan. 7, 2021

State issues recommendations to local health departments and providers to accelerate safe vaccine administration statewide

Jan. 27, 2021

Order waiving restrictions on dentists relating to ordering and administering COVID-19 vaccines

June 11, 2021

Beyond the Blueprint — State Public Health Officer Order

July 26, 2021

Health Care Worker Protections in High-Risk Settings — State Public Health Officer Order

Oct. 8, 2021

AB-526 Dentists and podiatrists: Clinical laboratories and vaccines — becomes law

public, dental care teams and decisionmakers about oral health information, programs and policies. Limited oral health literacy is influenced by many factors but is considered a product of two key dimensions: (1) an individual’s capacity to obtain, process and use information; and (2) the dental practitioner’s capacity to communicate effectively to a culturally and linguistically diverse population. Basic literacy and health literacy are fundamental to putting sound public health guidance into practice and helping providers and consumers follow recommendations. During the COVID-19 pandemic, the California Department of Public Health (CDPH) Office of Oral Health partnered with the California Dental Association (CDA) and other organizations to develop and disseminate guidance and protocols based on national and state recommendations.4 This was to make it easier for providers and consumers to understand and apply information and services connected to oral health. The critical steps taken to respond to the COVID-19 pandemic specific to dental settings are listed in TA BLE 1 . 120

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COVID-19 Pandemic Local Conditions

COVID-19 has impacted some communities more than others because of conditions that expose workers and families to SARS-CoV-2. According to CDPH, the variation in infection and deaths by county reflects higher rates of COVID-19 faced by certain population groups, such as adults aged 65 and older, people with preexisting health conditions, Latinos, Blacks, Pacific Islanders, people with low income and the essential worker community.5 Furthermore, the capacity of hospitals to manage the cases has been a major consideration in imposing restrictions on activities at the local level. Depending on the conditions in a community, local health officers have issued or updated orders. Dental practitioners must follow local orders that are more stringent than the state’s public health orders. Therefore, CDPH has recommended that all practitioners continually evaluate the local conditions, which can be accomplished by regularly checking the California COVID-19 Statewide Case Statistics dashboard for case information by county. A key statistic to watch is the positivity rate.6

General Considerations

In addition to local conditions, CDPH recommended that dental practitioners consider several factors that affect the provision of dental care. These include the availability of supplies, screening and testing and posting visual signs in the office. In addition, visual signs for respiratory hygiene, hand hygiene and cough etiquette are important to prevent transmission. The National Institute for Occupational Safety and Health (NIOSH) has proposed the hierarchy of controls as a strategy to minimize the risk associated with occupational hazards.7 FIGURE 1 shows that the control methods at the top are potentially more effective and protective than those at the bottom. The most effective step in a dental setting is to screen patients and employees to rule out COVID-19 status. However, all practitioners must be cognizant of asymptomatic cases. In addition, getting vaccinated will protect providers and employees. Until a practical, highly accurate point-of-care rapid test is available to identify COVID-19 patients, a symptom-based strategy should be employed to reduce the risk of exposure. The testing-based strategy is recommended for symptomatic patients who need to be seen for emergency conditions. A new law passed in October 2021 allows California-licensed dentists to apply for the requisite laboratory licensure to administer rapid COVID-19 tests in the dental office. Several point-of-care rapid COVID-19 tests have been approved by the Food and Drug Administration (FDA) under the Emergency Use Approval process. However, rapid tests for ruling out asymptomatic cases in a dental setting are not recommended because this test may give false-negative results. The CDA COVID-19 testing toolkit describes the federal and state

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Most effective

requirements for testing patients in a dental office and the potential to use such a strategy in the future.

Dental Practice Specific Considerations

The Centers for Disease Control and Prevention (CDC) provided interim guidance for infection control practice during the COVID-19 pandemic.1 The CDC updated the Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic in September 2021, and it applies to all U.S. settings where health care is delivered, including dental settings. The recommendations are categorized into two sections: routine infection prevention and control (IPC) practices during the COVID-19 pandemic and infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARSCoV-2 infection. In addition, the CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices for all patients. The additional dental facility-specific guidance is shown in TA BLE 2 .

Practice of Dentistry and Infection Control

The California Code of Regulations includes minimum standards for infection control.8 It specifies that all DHCP shall comply with infection control precautions, enforce the minimum precautions to protect patients and DHCP and minimize the transmission of pathogens in health care settings as mandated by Cal/OSHA. Several Cal/OSHA standards apply to dentistry, including §5193. Bloodborne Pathogens,9 §5199. Aerosol Transmissible Diseases10 and

Elimination

Physically remove the hazard

Substitution

Replace the hazard

Engineering controls Administrative controls PPE

Isolate people from the hazard Change the way people work Protect the worker with personal protective equipment

Least effective FIGURE 1. Hierarchy of controls from the National Institute for Occupational Safety and Health.

§3205. COVID-19 Prevention.11 The bloodborne pathogens standard applies to occupational exposure to blood or other potentially infectious materials like saliva in the dental setting. Dental practices are exempt from the aerosol transmissible diseases (ATD) standard provided they meet several conditions, including: ■ Dental procedures are not performed on patients identified to them as ATD cases or suspected ATD cases. ■ The Injury and Illness Prevention Program includes a written procedure for screening patients for ATDs that is consistent with current guidelines issued by the CDC for infection control in dental settings, and this procedure is followed before performing any dental procedure on a patient to determine whether the patient may present an ATD exposure risk. ■ Employees have been trained in the screening procedure. ■ Aerosol-generating dental procedures are not performed on a patient identified through the screening procedure as presenting a possible ATD exposure risk unless a licensed physician determines that the patient does not currently have an ATD.

On June 27, 2021, Cal/OSHA revised the previously approved emergency temporary standards (ETS) on COVID-19 infection prevention requiring additional precautions.11 These temporary standards apply to most workers in California not covered by Cal/OSHA’s ATD standard. According to Cal/OSHA, all employers are expected to comply with all provisions of the ETS, and Cal/OSHA will enforce this standard, taking into consideration an employer’s good faith efforts to comply. The CDA COVID-19 Addendum Injury and Illness Prevention Program is a model plan that will help dental practices to comply with the following aspects of the ETS regulations: 1. Authority and responsibility. 2. Identification and evaluation of COVID-19 hazards. 3. Correction of COVID-19 hazards. 4. Control of COVID-19 hazards: ■ Face coverings. ■ Engineering controls. ■ Cleaning and disinfecting. ■ Hand sanitizing. ■ Personal protective equipment (PPE) used to control employees’ exposure to COVID-19. ■ Testing of symptomatic employees. 5. Investigating and responding to COVID-19 cases in the workplace. FEBRUARY 2 0 2 2

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TABLE 2

Additional CDC Dental Setting-Specific Considerations Dental health care personnel (DHCP) should regularly consult their state dental boards and state or local health departments for current information and recommendations and requirements specific to their jurisdictions, which might change based on the level of community transmission in the county where their health care facility is located. Postpone all nonurgent dental treatment for: 1) patients with suspected or confirmed SARS-CoV-2 infection until they meet criteria to discontinue transmission-based precautions and 2) patients who meet criteria for quarantine until they complete quarantine. • Dental care for these patients should only be provided if medically necessary. Follow all recommendations for care and placement for patients with suspected or confirmed SARS-CoV-2 infection. • If a patient has a fever strongly associated with a dental diagnosis (e.g., pulpal and periapical dental pain and intraoral swelling are present) but no other symptoms consistent with COVID-19 are present, dental care can be provided following the practices recommended for routine health care during the pandemic. When performing aerosol-generating procedures on patients who are not suspected or confirmed to have SARS-CoV-2 infection, ensure that DHCP correctly wear the recommended PPE (including a NIOSH-approved N95 or equivalent or higher-level respirator in counties with substantial or high levels of transmission) and use mitigation methods such as four-handed dentistry, high-evacuation suction and dental dams to minimize droplet spatter and aerosols. • Commonly used dental equipment known to create aerosols and airborne contamination include ultrasonic scaler, high-speed dental handpiece, air/water syringe, air polishing and air abrasion. Dental treatment should be provided in individual patient rooms whenever possible. To prevent the spread of pathogens, dental facilities with open floor plans should do the following: • Maintain at least 6 feet of space between patient chairs. • Erect physical barriers between patient chairs. Easy-to-clean, floor-to-ceiling barriers will enhance effectiveness of portable HEPA air filtration systems (check to make sure that extending barriers to the ceiling will not interfere with fire sprinkler systems). • Orient operatories parallel to the direction of airflow if possible. • Where feasible, consider patient orientation carefully, placing the patient’s head near the return air vents, away from pedestrian corridors and toward the rear wall when using vestibule-type office layouts. • Account for the time required to clean and disinfect operatories between patients when calculating daily patient volume.

6. System for communicating. 7. Training and instruction. 8. Exclusion of COVID-19 cases and employees who had a close contact. 9. Reporting, recordkeeping and access. 10. Return-to-work criteria.

Vaccination

Vaccination is one of the most important tools to end the COVID-19 pandemic. The state has assured the public that safe and effective vaccines will be equitably distributed to everyone in California who wants them. Vaccinate ALL 58 is California’s 122

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COVID-19 vaccination program in all 58 counties.12 The state has created a COVID-19 Response Toolkit with images and videos that can be posted on social media.13 Additionally, CDA has developed the comprehensive Vaccine Confidence Toolkit to provide assistance and support to dentists. According to a new law, a dentist may independently prescribe and administer to persons aged 3 years or older influenza and COVID-19 vaccines approved or authorized by the Food and Drug Administration in compliance with the individual federal Advisory

Committee on Immunization Practices (ACIP) influenza and COVID-19 vaccine recommendations and published by the CDC. The California COVID-19 Vaccination Program has created resources for providers to enroll and administer vaccinations.14 Additional information about the enrollment process, onboarding and vaccine management, administration and reporting requirements are available at EZIZ’s COVID-19 website.15

Oral Health Information for Consumers

California’s local oral health programs have used various materials to educate the public about COVID-19 and oral health, including information for parents about visiting the dental office. The Smile, California campaign has created a flier and video called “What You Should Know About Returning to the Dentist During COVID-19,” which provides helpful information to Medi-Cal beneficiaries about dental visits and a discussion about the availability of video appointments.16

Conclusion

During this unprecedented COVID-19 pandemic, the numbers of cases, variants and geographic distribution are constantly changing. In addition, new knowledge about the virus, testing methods, vaccines and therapeutics is also constantly emerging. Governmental agencies and professional organizations update and adjust the recommendations based on the changing nature of the pandemic and provide toolkits to comply with laws and regulations. Therefore, dental practitioners must use current information to update their practices regularly. n RE F E RE N C E S 1. Centers for Disease Control and Prevention. Guidance for dental settings. Interim infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) pandemic.

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2. The invisible barrier: Literacy and its relationship with oral health. A report of a workgroup sponsored by the National Institute of Dental and Craniofacial Research, National Institutes of Health, U.S. Public Health Service, Department of Health and Human Services. J Public Health Dent Summer 2005;65(3):174–82. doi: 10.1111/j.1752-7325.2005. tb02808.x. 3. California Department of Public Health. California Oral Health Plan 2018-2019. 4. California Department of Public Health. Guidance for Resuming Deferred and Preventive Dental Care. 5. California Department of Public Health. California’s commitment to health equity. 6. California Department of Public Health. COVID-19: Case Statistics. 7. Centers for Disease Control and Prevention. The National Institute for Occupational Safety and Health (NIOSH). Hierarchy of Controls. 8. California Code of Regulations. §1005. Minimum Standards for Infection Control. 9. California Code of Regulations. Title 8. § 5193. Bloodborne Pathogens. 10. California Department of Industrial Relations. Cal/OSHA. The California Workplace Guide to Aerosol Transmissible Diseases. 11. California Department of Industrial Relations. Cal/OSHA. COVID-19 prevention emergency temporary standards - fact sheets, model written program and other resources. 12. California Department of Public Health. Let’s get immunity. 13. California Coronavirus COVID-19 Response Toolkit. 14. California Department of Public Health. Training and Resources. Required training for providers in the California COVID-19 vaccination program. 15. California Department of Public Health. COVID-19 vaccination program. 16. Smile, California. Latest news and COVID-19 information. THE AU THO R , Jayanth Kumar, DDS, MPH, can be reached at Jayanth.Kumar@cdph.ca.gov.

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Pursue smart employment practices.

As a CDA member, you have access to a full library of helpful resources for employers, plus the expertise of dedicated Practice Support analysts. Better understand training requirements, paid sick leave, wage and hour laws, notices and more. And save time with our custom employee manual generator. Explore your CDA member resources at cda.org/EmploymentPractices.

PRACTICE SUPPORT

Dental Benefit Plans Employment Practices Regulatory Compliance Practice Management

Dr. Stephanie Sandretti Member since 2015

RM Matters

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The Employee Manual: An Important Tool for Communicating Employment Conditions and Expectations TDIC Risk Management Staff

recent viral video parodies the plight of hiring managers. After admiring a hand-drawn “resume’” and checking the job candidate’s pulse, the manager asks, “When can you start?” While the fictitious interview was meant to be comedy, the struggle to find candidates to fill open positions is a reality for most employers in today’s market. The results of a November 2021 poll from the ADA Health Policy Institute found that 9 out of 10 hiring dentists indicate that it has been “extremely” or “very” challenging to recruit dental hygienists and dental assistants in the past year. In a climate of such need, it is understandable that dentists who find qualified and available new employees are eager to have them begin working as quickly as possible. However, prioritizing job duty training over educating new employees about crucial office policies can lead to miscommunication and increased risk of misconduct. The Dentists Insurance Company’s dedicated Risk Management analysts advise you to minimize risk by documenting your practice’s employment policies and making sure all employees — both seasoned and new — are offered training on the practical implementation of and adherence to those policies.

A case study in employment practices A phone call received by TDIC’s Risk Management Advice Line came from a practice owner who needed guidance on handling the aftermath of an employee’s termination. The

employee in question was a dental assistant who displayed stellar work habits during the first 90 days of employment. Unfortunately, in the days that followed, the dental assistant developed an attitude that was out of sync with the culture of teamwork the practice owner felt was established within the office. For example, the

practice owner noticed the assistant rolled her eyes when asked to do things. Problems with the employee escalated from that point. In another instance, after being asked to clean the last operatory of the day, the employee responded by throwing her sterilization gloves down on the counter, then further demonstrated

answers

From one-on-one risk management advice by phone to informed consent forms to expert-led seminars, we’re here to help you practice with confidence. We are The Dentists Insurance Company. Learn more at tdicinsurance.com/rm

Protecting dentists. It’s all we do.

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her anger by slamming items around the room as she cleaned. The assistant arrived late to work most mornings and frequently complained to other staff about their office being too busy and the lack of opportunity to take scheduled breaks. Her interaction with other staff members became increasingly strained. When the new employee’s behavior became intolerable, the practice owner made the decision to terminate the employment. He called the employee one evening after work to let her know that her services were no longer needed. The practice owner was relieved to end the association with an employee who had disrupted what he felt had previously been a positive working environment for his staff. You can imagine this dentist’s shock and dismay when, a few weeks later, he received a letter from an attorney representing the ex-employee, requesting a copy of her personnel file. When the practice owner contacted TDIC’s Risk Management Advice Line for guidance, he told the Risk Management analyst that he didn’t feel the issues during the ex-employee’s time in his practice warranted a discussion to address concerns about her work. He assumed that the employee was well aware of her behavior and the negative impact it had on the team. He concluded that she simply didn’t care how she was perceived by him or her teammates and expected to be terminated. When asked if the office had an employee manual that referenced his office’s employment practices, attendance or rest and meal break policies, the practice owner stated that he treated his employees as “family.” In the past, all employees got along well without conflict, so he didn’t think it was necessary to establish any formal protocols. 126

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According to TDIC’s Risk Management team, often a request for a copy of an employee’s personnel file from a legal representative is followed by another letter threatening further legal action with allegations such as wage and hour violations – including failure to provide meal and rest breaks, failure to pay meal and rest break premiums and failure to provide wage statements. Such accusations are made in response to the termination of the employee and are also accompanied by a settlement demand to resolve these

A customized, up-to-date employee manual is an easily implemented yet powerful tool to improve and safeguard your practice.

claims. The attorney may purposely avoid addressing any issues pertaining to the termination if this is not the strongest case and instead call into question the level of administrative oversight performed by the office.

Mitigating risk begins with communicating expectations

A lawsuit filed by a current or former employee is a difficult way to learn the importance of effectively documenting and communicating the conditions and expectations of employment within your practice. It’s best to provide documentation of office standards and ensure that all employees — regardless of position or tenure — acknowledge recognition and understanding of those standards. Not only should priority be given to sharing

your practice’s employment policies during new-employee onboarding, but time should also be devoted to reviewing the policies with all staff on a regular basis. TDIC’s Risk Management analysts urge dentists to utilize an employee manual to effectively document and share workplace expectations and policies. A customized, up-to-date employee manual is an easily implemented yet powerful tool to improve and safeguard your practice. It can be your primary defense in everything from day-today office disputes to full-blown legal claims, along with minimizing confusion and miscommunication about policies and regulations. An employment manual like this is also beneficial to employees, giving them a roadmap of your expectations. Think of this resource as a guide of your practice’s culture, which includes benefits, dress code, punctuality and attendance expectations. By clearly outlining these policies, following and documenting them formally in an employee manual, you avoid unfairly or inadvertently singling someone out when course correction is necessary. An employee manual also simplifies the performance evaluation and corrective action process, as reference to performance — improved or needed — can be related back to your established office policies. TDIC policyholders have access to downloadable sample employee manuals specific to the state in which they practice. CDA members also have access to a sample employee manual through Practice Support as well as an employee manual generator. These are excellent resources to efficiently create or update dentistry-focused required and optional office policies.

Prevent and be protected against costly lawsuits

While having an employee manual itself is not a legal requirement, there

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are many sound legal reasons for having one. Certain employment laws require employers to notify employees of certain workplace rights in writing, so a well-developed manual that can be given to employees is an important step in documenting your compliance with federal, state and local employment regulations. By outlining employment laws and any other standards your practice adheres to, along with the consequences of policy violations, within the form of a manual and recording employees’ acknowledgement of reading that manual, you have the protection of due diligence on your side. The absence of employer policies greatly increases the likelihood of an employee filing suit. Practices that don’t have employee manuals are considered proverbial low-hanging fruit for successful lawsuits, because the lack of an employ manual is indicative of potential negligence in other aspects of the business. Having written policies is one of the simplest yet most effective ways to deter opposing legal counsel from deciding to file a lawsuit.

Keep policies current and specific

Just as you update tools and technology in your practice environment, make sure your employee manual keeps pace with regular updates. Having an employee manual that contains outdated or erroneous policies can be almost as dangerous as having no manual at all. It should be a living document — one that you add to or subtract from in cadence with changing employment laws and practice guidelines. It may be tempting to adopt another practice’s manual or utilize a generic manual provided by your payroll company. Unfortunately, simply copying the contents of another company’s

employee manual is unlikely to satisfy the unique human resource needs of your own workforce. You risk not being specific, consistent and objective. By outlining policies in your manual that are tailored to your practice to reference during employee communication, performance evaluations and disciplinary actions, you ensure every situation is handled objectively and consistently. Frequently, the root of poor employee performance is confusion, lack of clarity or an inconsistent approach to process. It can be validating for all employees to refer

Frequently, the root of poor employee performance is confusion, lack of clarity or an inconsistent approach to process.

back to the manual when questions arise. Furthermore, adherence to policies outlined in an employee manual strengthens the role of the dentist as leader in the practice.

Creating and implementing an employee manual

TDIC’s sample manuals and CDA’s employee manual generator contain content developed by employment attorneys and HR specialists. Their understanding of state employment laws and dental employment practices offers a sound starting point for your manual. Most importantly, both tools can be customized to meet the needs of your practice. They include: ■ Standards for performance and protection against HRrelated legal claims.

■

Best practices tailored to your practice’s unique goals and culture. Federal and state-compliant policies for your practice’s size and location.

Before you begin the process of creating an employee manual, prepare to address human resources policies that apply to your practice, including: ■ Details of benefits offered (PTO, holidays, health insurance, in-house benefits, etc.). ■ Mandatory paid sick leave requirements for full- and part-time employees. ■ Rate of pay for mandatory meetings, training, travel time and on-call work. ■ Alternate work schedule and its impact on benefits, as applicable. ■ Dress code or uniform standards. Once you have created or updated your employee manual, it’s time to implement it in your practice. If you have been working without an employee manual or using a generic one, make time to introduce the new document to your employees during a staff meeting. For new employees, during onboarding, prioritize giving them access to the document, offering an overview of important points, allowing them time to read it during the workday and recording their acknowledgment of receipt and understanding. Whether you are implementing an employee manual for the first time or already have a robust manual in place, consider the following: ■ Do your employees have access to a current copy of the manual? ■ Have you kept records showing that your employees acknowledged reading the manual? ■ Are any changes or updates you’ve made to the manual also acknowledged by employees? FEBRUARY 2 0 2 2

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Are you referring to practice policies within the manual during new-employee onboarding or disciplinary actions? Practice owners should consider an employee manual one of the most important documents in their human resources tool kit. Not only can definitive employee policies resolve disputes, they can also thwart issues before they arise, protecting both the employer and the employee from any misperceptions and the potential for litigation. Taking time to document your practice policies in an employment manual and introducing your policies to all employees is an important investment in the long-term well-being of your dental practice. n ■

The Dentists Insurance Company’s Risk Management Advice Line is a benefit available at no cost to CDA members, as well as to policyholders protected by TDIC. Visit tdicinsurance.com/RMconsult or call 800.733.0633 to schedule a consultation.

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CDA member benefit: Access to education any time Online Learning is your destination for 24/7 education. Enjoy waived fees and big discounts on popular courses, including:

• Bloodborne Pathogens: Post-Exposure Management $150 - CDA members get 50% off

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IT’S EASY TO GET STARTED! Already a CDA member? Set up your Online Learning account with the same email you use to access your cda.org account to ensure access to the member-only catalog and special pricing. Then, sign in any time to explore all your course options and start learning! Not yet a member? Set up your account and sign in to access select courses, or join CDA to benefit from discounts and expanded learning options.

cda.org/online-learning

Making your transition a reality.

Dr. Thomas Wagner

Dr. Russell Okihara

LIC #01418359

LIC #01886221

Jim Engel LIC #01898522

(916) 812-3255 (619) 694-7077 (925) 330-2207 47 Years in Business 40 Years in Business 48 Years in Business

Jay Harter LIC #01008086

Kerri McCullough LIC #01382259

Gina Miller LIC #02015193

Steve Caudill LIC #00411157

Jaci Hardison LIC #01927713

Christy Conway LIC #: #02143744

Kim Ta LIC #02085576

Thinh Tran LIC #01863784

(916) 812-0500 (949) 300-0312 (707) 391-7048 (714) 318-4911 (951) 314-5542 (408) 687-5001 (619) 889-6492 (949) 675-5578 39 Years in Business 37 Years in Business 32 Years in Business 32 Years in Business 28 Years in Business 19 Years in Business 18 Years in Business 13 Years in Business

PRACTICE SALES • VALUATIONS/APPRAISALS • TRANSITION PLANNING • PARTNERSHIPS • MERGERS • ASSOCIATESHIPS NORTHERN CALIFORNIA ALAMO: New Listing! 3 Ops, Digital, 13 Yrs Goodwill, Desirable Area, Not in Delta Network. 2019 GR $642K. #CA2968 AUBURN: New Listing! 4 Ops+RE, 60 Yrs. Goodwill, Dentrix, Digital, Laser, CEREC, Room to Grow w/ specialties. 2019 GR $632K. #CA2809 EAST BAY AREA PEDO: Well-established with 8 Ops, Digital, plumbed for Nitrous, and high NP count. Associate-driven with Delta PPO. 2019 GR $832K on 3-4 days/wk., 2020 Production $560K. #CA2523 FAIRFIELD AREA: New Listing! 4 Ops w/1 add’l +RE, Digital, Paperless, Strong Hyg. Program, Not in Delta Network. 2019 GR $714K. #CA2955 FAIRFIELD AREA: High traffic area, 7 Ops Digital, Pano/CB, 23+ NP/mo. with 8+ Hyg. days/wk. Room to grow with specialties. 2019 GR $1.7M and 2021 on track to exceed 2019. #CA1824 FREMONT ORAL SURGERY: 34 yr history, diverse high-tech community. 4 Ops Digital, 7-10 y/o equipment, Pano. 2019 GR $548K on 3.5 days/wk. #CA2754 GREATER SONORA AREA: Rural lifestyle GP/Real Estate, 5 Ops, Dentrix, Strong hyg prog in stable community. 2019 GR $698K. #CA1713 LAKE TAHOE AREA: 4 Ops, 37+ yrs Goodwill. Rural lifestyle GP in growing resort community. 2019 GR $760K. #CA1715 MILLBRAE: Great practice in the heart of the peninsula with 60 yrs goodwill. 5 Ops. 2019 GR $1M+ on 4 days/wk. and 6 Hygiene days. Owner will work back for a short time for transition. Digital, Pano, Waterlase & Periolase. #CA1139 NAPA COUNTY: New Listing! 7 Ops, stand-alone building. Gross Revenue over $1M+ with 7 Days of Hygiene. Computerized and Digital. Established in the community for over 37 years. #CA2912 NORTHERN SACRAMENTO: Busy location, Paperless, 3 Ops+4th shared, CEREC, Digital Pano. 2019 GR $671K on 24-32 hrs/wk. #CA1745 OAKLAND: Pill Hill area, walk to BART, 2019 GR $473K. 3 Ops, Digital X-rays and Pano. #CA2839 PLEASANTON: New Listing! 7 Ops, 5 Equipped, Dentrix, Digital, Laser, Digital Pan, no need to add $, this practice has everything. GR $1.3M. Won’t last. #CA2891 REDDING: Modern office with 5 Ops, 4 Eq., Digital, Newer CEREC, 23 NP/mo with no marketing. Strong Hygiene, specialties referred. 2019 GR $558K. #CA1742 ROCKLIN/GRANITE BAY: High-end 4 Op GP/Cosmetic practice in affluent area. Paperless, digital, iTero scanner, 8+ hyg. Days/wk. 2019 GR $1.6M+, 2021 Prod projected at $2M+. RE for sale with practice. #CA2793 ROSEVILLE/CITRUS HTS: New Listing! 4 Ops with 18 Yrs Goodwill, Digital, Laser, Strong Hyg., Specialties Referred, 2021 est GR $775K. #CA2897

MODESTO AREA: Est. area with 60+ yrs. ROSEVILLE/CITRUS HTS: 6 Ops, high traffic area, 13 yrs goodwill, Digital, lasers, 26 goodwill. 5 Ops, 2019 GR $1.1M+ on 3 days/wk. Dental Condo also available for NP/mo, 5 days Hygiene, specialties referred. purchase or lease, Seller may consider Seller will work back. #CA2749 financing. #CA635 ROSEVILLE/ROCKLIN: New Listing! MONTEREY: 4 Ops, Paperless, Digital, 7 Ops, hi-end practice in desirable area. Pano. 2019 GR $1.1M with Adj. Net over Digital, CAD/CAM, lasers, Pano. 10+ hyg. $450K. Post-COVID revenue has grown days/wk, 2019 GR $2.3M, 2021 projected $2.5M. Lease with purchase option. #CA2770 even more! RE for sale, non-Delta Premier office, FFS and some PPOs. #CA2614 SAN FRANCISCO PEDO: New Listing! 7 Chairs, Digital, Nitrous, Digital Pan, Beautiful SANTA CRUZ: New Listing! 4 Ops, Minutes to beach! Digital, CEREC, Pano, Office w/ <10 y/o equipment. 2019 GR CBCT. Bread and butter practice-room to $953K. #CA2953 grow with specialties. FFS and Delta PPO SAN FRANCISCO: New Listing! 4 Ops, only. #CA2938 Financial District, SoftDent, Digital sensors SANTA CRUZ COUNTY: 4 Ops, near and Pan. FFS/PPO, GR $1.6M+. Delta PPO beach, in strip center. Digital Pano, X-rays, Practice with over 70 NP/mo. #CA2934 CEREC, 40 years goodwill. 2019 GR SAN JOSE: Est for 35 yrs, 2019 GR of $392K on 3.5 days. #CA2822 $1.3M with Adj. Net of 38%. 6 Ops, Digital SANTA CRUZ/APTOS PERIO: 4 Ops X-rays and Pan, CAD/CAM, Laser. Upscale building near shopping. Seller can stay on P/T. +RE, Paperless, Digital, CBCT, 27 years goodwill. Seller will help with smooth #CA1140 transition of strong referral base. #CA2725 SAN MATEO: Price Reduction! 5 Ops, Digital, iTero Scan, CEREC, Laser, Paperless, SOUTHERN CALIFORNIA Microscope. Seller-owned stand-alone building to lease. $1.4M GR on 4 days/wk. BAKERSFIELD: New Listing! 7 modern #CA2596 Ops, FFS/PPO. Eaglesoft, Digital, M11 and SONOMA COUNTY: Price Adjustment! Digital Pano. RE potentially for sale also. Large GP, 2019 GR $2.3M+. Stand-alone Doctor selling due to family emergency 3,000 sf prime Real Estate, 72 NP/mo. & 10 highly motivated. #CA2945 Hyg Days. 6 Ops, Pano, Dexis, Cameras, BAKERSFIELD: 6 Ops, 40 yrs Goodwill, Laser, Dentrix. Both Business & RE for sale great reputation in the area. 6 hyg ds/wk and or Lease. Doctor Retiring. #CA544 most specialty work referred. Digital pano, SONOMA COUNTY: 4 Ops in spacious digital X-rays. 2019 GR $600K. RE also for layout in heart of the area off main highway. sale. #CA1274 Est 22 yrs with 5 star Google reviews, BAKERSFIELD: 6 Ops, 5 Equipped, Digital, Paperless with CEREC, Scope, Laser, Strong 2020 Collections $1M+ with 6 days hygiene Hyg. Retiring seller. 2019 GR $782K with and 2 P/T associates. #CA2587 good post-COVID recovery. #CA2594 BURBANK: Big opportunity for large SONOMA COUNTY: New Listing! 4 Ops practice merger, 6 Ops, Digital, seller retiring. with room to expand into suite next door. GR over $1M for last 3 yrs. Est. 30+ years. Strong 6 days of hygiene, specialties referred. Seller will transition, open to financing options. hygiene, digital, space available to lease or 2019 GR $918K. #CA2632 buy. #CA2790 HUNTINGTON BEACH: New Listing! SONORA AREA: 5 Ops, Producing $825K 5 Ops, established 30 yrs. RE ownership in a renovated suite. RE for sale w/practice. available. PPO with specialties referred - room Strong Hyg program. Digital, Laser, and to grow. High net income in sought-after area. Digital Pano. #CA2850 #CA2937 S. SACRAMENTO-GREENHAVEN: LONG BEACH: RE Ownership an option! Associate in place. 4 Ops, Digital, Cone Upper middle-class residential practice est. in Beam, Digital Pano, Specialties referred. Not 1950. Existing 4 Ops, 3 Equip, Digital, Easy a Delta Premier Provider. 2021 projected expansion next door to add 3 Ops, 2 are equip. $800K+. #CA2741 Most Specialty referred. Strong post-COVID VACAVILLE AREA: 4 Ops, 3 equipped, 45 production. 2019 GR $696K. #CA671 years goodwill, Digital, paperless, most MONTEBELLO: New Listing! 3 Ops in busy specialties referred. 2019 GR $723K on 30 strip center location with 2 Associates, Digital hour week. #CA2748 X-rays, and all specialty work referred out. #CA2786 CENTRAL CALIFORNIA ORANGE COUNTY: New Listing! 8 Ops, 6 FRESNO AREA: New Listing! 6 Op Valley equipped, room to bring in specialists! Digital, gem, great staff in desirable area. Paperless, BioLase, iTero, Digital Pan, beautiful office, Trios Scanner, Digital Pan/Ceph, Lasers and modern and clean. Premium strip center 12 days of hyg/wk. 2019 GR $1.4M, 2021 location. GR $590K. #CA2926 projected at $1.4M again. Seller may consider option to purchase RE. #CA2004 GREATER MODESTO: New Listing! 7 Ops, Desirable area, Dentrix, Digital, Laser, Digital Pano. RE for sale w/practice. Not a Delta Premier provider. 2020 GR $615K and 2021 should exceed it. #CA2795

Northern California Office

800.519.3458

Henry Schein Corporate Broker #01230466

www.HenryScheinDPT.com

ORANGE COUNTY: 4 Ops in soughtafter area. 34 yrs Goodwill, many hi-end procedures done in-house but room to grow other specialties. Digital. FFS/Cash. #CA2704 PALM DESERT: 4 Ops 27 yrs Goodwill. Strong hyg prog w/ hi-end patient base of locals/snowbirds. 2019 GR $809K on only 16 days/mo. with low overhead. Call today! #CA691 PALMDALE/LANCASTER: 7 Op office in fast-growing community. Paperless with Dentrix, digital X-rays, 8 days of hyg./week and dedicated staff. Room to grow with specialties! #CA2612 SAN BERNARDINO: New Listing! 6 Ops, established 33 years, cash, HMO, Denti-Cal in a busy area with parking. Estimated GR for 2021 at $960K+. Seller offering RE for sale with 2 lease tenants adjacent to practice. Room to expand with spec. #CA2843 SANTA BARBARA: 4 Ops in beautiful setting. Digital, FFS, strong hygiene, and room to grow with specialties. Consistently collects $1M+/yr. with manageable overhead. #CA2531 TORRANCE: 3 Ops, room for a 4th. Dentrix, digital, refers most specialties with low overhead and high net. GR $600K. #CA2815 TORRANCE:3 Ops, retiring seller with 34 yrs goodwill. Ready to take to the next level with technology of your choosing. Amazing location in desired area. 2019 GR of $300K with low expenses, a wonderful opportunity to grow. #CA2807

SAN DIEGO CARLSBAD: New Listing! 5 Ops, modern design, suburban growing area. Digital Pan, Digital sensor, Laser, Paperless. 30 NP/mo. Room to grow with marketing and specialties. #CA2933 ENCINITAS: New Listing! 5 bright Ops, strip mall location. Digital Pan, Laser, Digital X-rays, Paperless. 25 NP/mo. Grow with specialties. #CA2935 ESCONDIDO: New Listing! 6 Ops, hi-prod, CBCT, Scanner, Scope, Laser. Off main road, refers out most specialties. #CA2946 N. SAN DIEGO INLAND FACILITY: 5 Ops, 4 equipped plus a 4 chair ortho bay. Excellent space for GP looking to expand or specialist. #CA2840 POWAY: New Listing! 6 Ops, Dentrix, Dexis, CBCT, laser, solid foundation. Main road location with free parking. #CA2932 SAN DIEGO: New Listing! 4 Ops, desirable/ affluent community. CEREC, CBCT, Digital, Dentrix, Paperless. Room to grow with specialties. #CA2896 SAN DIEGO: New Listing! Rare opportunity, seller retiring, 4 Ops in desirable location with good cash flow. High quality work. Digital, Dentrix. #CA2851

Southern California Office

888.685.8100

Regulatory Compliance

C D A J O U R N A L , V O L 5 0 , Nº 2

Q&A: Dental Scope of Practice CDA Practice Support

entists may attend courses that instruct on performing certain procedures. However, attending a course does not necessarily mean that a California dentist may perform that procedure. A dentist may perform procedures permitted by their state’s laws. Each state has its own scope of practice. California’s dental scope of practice is found in Business & Professions Code section 1625, which states:

c) In any way indicates that the person will perform by themselves or their agents or servants any operation upon the human teeth, alveolar process, gums, jaws or associated structures or in any way indicates that the person will construct, alter, repair or sell any bridge, crown, denture or other prosthetic appliance or orthodontic appliance.

d) Makes or offers to make an examination of, with the intent to perform or cause to be performed any operation on the human teeth, alveolar process, gums, jaws or associated structures. e) Manages or conducts as manager, proprietor, conductor, lessor or otherwise a place where dental operations are performed.

Dentistry is the diagnosis or treatment, by surgery or other method, of diseases and lesions and the correction of malposition of the human teeth, alveolar process, gums, jaws or associated structures; and such diagnosis or treatment may include all necessary related procedures as well as the use of drugs, anesthetic agents and physical evaluation. Without limiting the foregoing, a person practices dentistry within the meaning of this chapter who does any one or more of the following: a) By card, circular, pamphlet, newspaper, internet website, social media or in any other way advertises themselves or represents themselves to be a dentist. b) Performs, or offers to perform, an operation or diagnosis of any kind, or treats diseases or lesions of the human teeth, alveolar process, gums, jaws or associated structures or corrects malposed positions thereof. FEBRUARY 2 0 2 1 LDM_CDA_Journal_1.3_Square_LindaBrown_05_23_17.indd 1

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May a dentist perform a cosmetic procedure?

The Dental Board of California has advised that cosmetic procedures, and the use of appropriate products for those procedures, that are performed for the treatment of diseases and lesions and the correction of malposition of the human teeth, alveolar process, gums, jaws or associated structures and are part of a dental plan fall into the definition of the practice of dentistry. A dentist who does not hold an elective facial cosmetic surgery permit may only provide Botox and dermal fillers for cosmetic purposes when administered as part of a comprehensive dental treatment plan. The documentation should be explicit, detailed and include photographs. An oral surgeon with an elective facial cosmetic surgery (EFCS) permit is the only dentist who may provide cosmetic services on a standalone basis. Enforcement actions have been pursued against general dentists who perform cosmetic procedures for the sole purpose of cosmetic improvements of facial tissues rather than for cosmetic improvements related to dental treatment.

What is a dentist permitted to do with a patient who may have sleep apnea? It is appropriate for dentists to screen patients for signs and symptoms of sleep-disordered breathing and to work with physicians to diagnose and treat sleep-disordered breathing. However, the diagnosis of sleep apnea is solely within a physician’s scope of practice in California.

May a dentist perform venipuncture? Venipuncture performed as part of dental treatment is considered to be within the dental scope of practice. After discussing the subject in 2019, the dental board chose not to consider additional regulation. The procedure may be performed in a dental 132

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practice by California active licensed dentists who have the knowledge and skill to perform it, registered nurses and certified phlebotomists.

May a dentist perform laser hair removal?

No. Laser hair removal is considered a medical procedure in California. n Regulatory Compliance appears monthly and features resources about laws that impact dental practices. Visit cda.org/ practicesupport for more than 600 practice support resources, including practice management, employment practices, dental benefit plans and regulatory compliance.

Tech Trends

C D A J O U R N A L , V O L 5 0 , Nº 2

A look into the latest dental and general technology on the market

Windows 365

($20 to $162 per month per users, Microsoft) Browser-based computing has always been an intriguing frontier because it allows users to run software tasks with nothing more than a web browser and internet connection. These tasks have grown to encompass complex, business-critical activities like word processing (via Google Docs), virtual meeting hosting (via Zoom) and even deployment of electronic health records (via Citrix Workspace). On the fringe of this frontier has lain the holy grail: Desktop as a Service (DaaS) or the ability to run an entire computer from the internet. Tech giants like Amazon, Citrix, VMware and Google have been racing each other to offer the simplest, cheapest and most effective DaaS. In July 2021, Microsoft shook the competition through Windows 365 Cloud PC, a subscription-based, virtual Windows computer accessible through any web browser. This review focuses on the Enterprise plan at $31 per month per user. What immediately sets Windows 365 apart from other products is its familiarity. Go to a webpage, sign in, and in seconds, users have access to their Windows computer. If the user has other Microsoft products, these resources are automatically synchronized. Software can be installed, and files can be interacted with like in Windows. On a desktop or laptop, the Remote Desktop app from Microsoft greatly enhances the user experience, as multiple monitors can be used and sound can be customized, but it is not a necessity. For users on mobile devices, even though a web browser does work, the Remote Desktop app is almost a prerequisite because the keyboard is not easily accessible without it. Windows 365 is highly reliant on internet bandwidth and has issues with media playback (especially video), but overall, it is admirable with its out-of-the-box compatibility with peripheral devices, ease of use and affordable price point. Having a web-browser computer seems like a novelty until users see that any device — laptop, desktop, phone or tablet — becomes a full-fledged computer, which means that hardware maintenance and lost productivity due to hardware failure are things of the past for those with Windows 365. Consequently, dental practices looking to improve security, resolve application licensing concerns and remove hardware maintenance headaches should consider utilizing Windows 365.

HOOBS ($219, HOOBS) Owning multiple smart home devices, each with their own separate apps and accounts, can be difficult to control and manage. Apple, Amazon and Google have each developed their own hub services, named HomeKit, Alexa and Nest respectively, to integrate these smart home devices. However, not all devices are compatible with these ecosystems. HOOBS, which stands for “Homebridge Out Of the Box System,” is an easy way to integrate unsupported smart home devices into Apple HomeKit. HOOBS is available in several versions: a starter kit that contains a plug-and-play hub, a microSD card with HOOBS preinstalled for Raspberry Pi or a downloadable image of HOOBS that can be flashed to a microSD card for use in a Raspberry Pi. When connected to the home network using ethernet, users can set up their hub through the web browser. After setup is complete, users simply install plug-ins from a library containing the most popular smart home device manufacturers available. Each plug-in has easy-tofollow instructions and specific information that needs to be entered to integrate with the hub. When a plug-in is installed and configured correctly, a HomeKit code is displayed that users can then scan in their Apple Home app to add their accessories. HOOBS accessories appear and function in Apple Home just like normal HomeKit accessories and can be individually controlled or added to automation schedules. Automatic software and plug-in updates ensure that the latest security and bug fixes are implemented. Because HOOBS is developed in the open-source community, some plug-ins require technical knowledge and advanced skills to be able to install and function properly. However, many accessories from popular manufacturers such as Ring, Philips Hue and myQ have easy configurations for their plug-in installations. Users who mainly have these devices and want to integrate them into Apple Home will find HOOBS to be simple to set up and operate, but experiences may vary. — Hubert Chan, DDS

— Alexander Lee, DMD

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Journa C A L I F O R N I A

D E N TA L

A S S O C I AT I O N

CDA Journal - February 2022: Living and Practicing With COVID-19

Articles inside

Tech Trends

Regulatory Compliance - Q&A: Dental Scope of Practice

RM Matters: The Employee Manual

COVID-19 and Oral Health Care: Implications for Dental Practices

Impact of COVID-19 on Dentistry

C.E. Credit: Safe Dental Care During the COVID-19 Pandemic

Dentistry's Collective Strength During Unprecedented Times

Introduction: Living and Practicing with COVID-19

Letter

Guest Editorial: The Rise of Podcasts