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ADA Guides Member Dentists Through COVID-19 Ethical Storm
Dr. Jonke practices general dentistry in Stony Brook, New York and is a member of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs and a Fellow of the American College of Dentists. Dr. Soileau practices periodontics in New Orleans, Louisiana, is a Diplomate, American Board of Periodontology and a Fellow of the American College of Dentists
Guenter Jonke, DMD, FACD Kristi Soileau, DDS, M Ed, MSHCE, FACD
Pandemic Panic
As we begin COVID19 vaccinations throughout the world in record time, we pause to reflect on what has transpired in the dental profession over the past 10 months. Dentistry has consistently been presented with ethical dilemmas throughout these challenging times of COVID-19, necessitating a close look at the historical timeline of the demands and the responses with which the profession has weathered during this ethical storm.
Dentists strive to serve the best interest of their patients’ dental needs, as the ADA’s over 150-year-old Principles of Ethics & Code of Professional Conduct states should be done. Yet in mid-March, when the realization that a worldwide pandemic of unknown duration was impacting the relationship between patient and caregiver, dentists were told to close their offices except to treat only those patients in acute, emergent situations,1,2 leaving the vast majority of patients of record without preventive and/or restorative dental care for an indefinite period.
Dentists followed the orders implemented in their states but were troubled about whether this was right for patients. Unease mounted as offices were shut down except for seeing what individual dentists considered to be the emergent case, second guessing the nuances of the imposed moratorium. Staff became either redundant or, at best, needed minimally. Questions arose about whether it would be right or prudent to relieve them of their positions, and in some instances, staff left their jobs-and the profession for good out of fear of the transmissibility of COVID-19.
The ADA’s Guiding Light
Throughout the pandemic, the ADA Health Policy Institute kept members abreast of many ethics and other professionally-related information, such as staffing, PPE availability and other data.3 Rather than leaving dentists to interpret the CDC’s initial guidelines as to what constitutes “emergent care,” the ADA was in communication with the CDC to ensure that dentistry had a voice. The ADA became the source for the dental profession providing information on what constituted a dental emergen-
cy, and created algorithms on triaging patients, screening protocols, and minimization of risks of disease transmission, among a multitude of other advisories.4
As more was learned of the routes and risks of transmission, dentists made changes to their offices and their procedures to reduce any risks with such guidance from the ADA, which provided daily communications to its members, ultimately benefitting all dentists around the world, with updates on the best, safest, and most ethical practices through the
various phases of COVID, guidelines from national health agencies, how to obtain much-needed PPE, return to work toolkits, and the availability of financial loans available for keeping businesses afloat.5
Guidance on professionalism was also achieved through concerted effort with ADA leadership and staff through the many webinars, podcasts, informational and consensus papers, online group meetings, that served as a lifeline to both dental practices and their patients. Topics addressed included: Provider Relief Fund and Labor Laws, SBA Loans Update, COVID PPE and Me, Regulatory Compliance during COVID-19, and 20 High Value Recovery Strategies, just to name a few offerings.6
Making Best Sense of It All
One major ethical quandary that existed through the earlier months was how to balance the risk of transmission to patients, staff, and families, while still providing necessary dental procedures. This was a delicate balance of meeting the individual needs of patients with the broader public health needs of the community. In an effort to close the gap on this issue,
the Council on Ethics, Bylaws and Judicial Affairs of the ADA then adopted Advisory Opinion 3.A.1., Elective and non-emergent procedures during a public health emergency, which in essence states that:
Dentists are able to provide oral health care for patients according to the patient’s desires and wishes, so long as the treatment is within the scope of what is deemed acceptable care without causing harm or impacting the public, such as during a public health care crises or emergency. In such extreme conditions, dentists should balance the competing ethical obligations to individual patients and the public.7 In the face of concerns about neglect of individual patients in the first months of the pandemic, some state dental leaders appealed to their respective departments of health to explain how certain maintenance procedures were in fact time sensitive and of medical importance, which opened the way for dentists in some states to practice more expanded procedures once deemed nonessential. According to Brian and Weintraub, oral health care should be a public health priority.8 Pertinent to this philosophy, a recent study out of Sinai Hospital
in Toronto, that was published in the Journal of Dental Research stated that patients with untreated periodontal disease are susceptible to more rapid and virulent responses to the COVID-19 virus.9 It is the continued investigation of the balancing of consequences caused by overtreatment versus undertreatment that will help us better define individual/community risk and benefits.
Despite the many restrictions, the ADA Health Policy Institute reported that as of November that 98% of dental offices were open, with 1/3 reporting “business as usual.”10 As of nine months from the start of the pandemic, the ADA reported that
Throughout the pandemic, the ADA Health Policy Institute kept members abreast of many ethics and other professionally-related information, such as staffing, PPE availability and other data.[3] Rather than leaving dentists to interpret the CDC’s initial guidelines as to what constitutes “emergent care,” the ADA was in communication with the CDC to ensure that dentistry had a voice. The ADA became the source for the dental profession providing information on what constituted a dental emergency, and created algorithms on triaging patients, screening protocols, and minimization of risks of disease transmission, among a multitude of other advisories.[4]
Guenter Jonke, DMD, FACD and Kristi Soileau, DDS, M Ed, MSHCE, FACD
fewer than 1% of US dentists had a COVID positive transmission.11 This is a testimonial to the exemplary efforts made by the dedicated leadership at the ADA, its member practitioners, the profession, as well as those who teach proper infection control and overall professionalism in our dental institutions. Although this pandemic has placed ethical burdens never before seen on the profession, it has nonetheless left dentists with more knowledge, resiliency, and determination as they continue to strive to meet their obligations to both individual patients and the wider community.
REFERENCES
1. Brian Z, Weintraub JA. Oral Health and COVID-19: Increasing the Need for Prevention and Access. Prev Chronic Dis. 2020;17:200266. DOI: http://dx.doi.org/10.5888/pcd17.200266 Accessed Jan. 20, 2021.
2. Burger, D. ADA recommending dentists postpone elective procedures. ADANews. March 16, 2020. https://www. ada.org/en/publications/ada-news/2020-archive/march/ada-recommending-dentists-postpone-electiveprocedures#:~:text=%E2%80%9CThe%20ADA%20is%20deeply%20concerned,for%20the%20next%20three%20weeks.
Accessed Jan. 20, 2021.
3. American Dental Association. Week of November 16, 2020- COVID-19 Economic Impact on Dental Practices. Published
December 3, 2020. https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPI_COVID_Webinar_
Nov_2020_2.pdf?la=en. Accessed Jan. 20, 2021.
4. Versaci, MB. ADA releases interim guidance on minimizing COVID-19 transmission risk when treating dental emergencies.
ADANews. April 01, 2020. https://www.ada.org/en/publications/ada-news/2020-archive/april/ada-releases-interim-guidanceon-minimizing-covid-19-transmission-risk-when-treating-emergencies. Accessed Jan. 20, 2021.
5. ADA Center for Professional Success. COVID-19 Practice Resources. https://success.ada.org/en/practice-management/ patients/practice-resources?utm_source=cpsorg&utm_medium=covid-nav&utm_content=nav-practice-resources&utm_ campaign=covid-19. Accessed Jan. 20, 2021.
6. ADA Center for Professional Success. COVID-19 Digital Events. https://success.ada.org/en/practice-management/patients/ digital-events?utm_source=cpsorg&utm_medium=covid-nav&utm_content=nav-digital-events&utm_campaign=covid-19.
Accessed Jan. 20, 2021.
7. American Dental Association. ADA Principles of Ethics and Code of Professional Conduct. With official advisory opinions revised to November 2020. https://www.ada.org/~/media/ADA/Member%20Center/Ethics/ADA_Code_Of_Ethics_
November_2020.pdf. Accessed Jan. 14, 2021.
8. Brian Z, Weintraub JA. Oral Health and COVID-19: Increasing the Need for Prevention and Access. [Erratum appears in Prev
Chronic Dis 2020;17. http://www.cdc.gov/pcd/issues/2020/20_0266e.htm.] Prev Chronic Dis 2020;17:200266. DOI: http:// dx.doi.org/10.5888/pcd17.200266external icon
9. Fine N, Chadwick JW, Sun C, et al. Periodontal Inflammation Primes the Systemic Innate Immune Response. Journal of Dental
Research. Oct. 2020; 1-8. doi:10.1177/0022034520963710. Accessed Jan. 14, 2021.
10. American Dental Association. Economic Impact of COVID-19 on the Dental Care Sector: Insights from Data for Week of
August 10th. https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPI_COVID_Webinar_Aug_2020_2. pdf?la=en. Accessed January 20, 2021.
11. Versaci, MB. ADA study finds COVID-19 rate among dentists less than 1%. ADANews. October 15, 2020. https://www.ada.org/ en/publications/ada-news/2020-archive/october/ada-study-finds-covid-19-rate-among-dentists-less-than-1-percent.
Accessed January 20, 2021.
