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

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

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.

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The 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 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 TABLE 1.

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 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 SARS- CoV-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 TABLE 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 Diseases [10] and §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.

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 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.

REFERENCES

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.

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 AUTHOR, Jayanth Kumar, DDS, MPH, can be reached at Jayanth.Kumar@cdph.ca.gov.