COVID-19 and dental practice Part-II

Introduction

As discussed in COVID-19 and dental practice Part-I, COVID-19, caused by the novel coronavirus SARS-CoV-2, first emerged in December 2019 in Wuhan, China. It rapidly evolved from a localized outbreak into a global pandemic, leading to unprecedented challenges for public health systems, economies, and societies worldwide. The World Health Organization (WHO) declared COVID-19 a Public Health Emergency of International Concern on January 30, 2020, and a pandemic on March 11, 2020. The virus spreads primarily through respiratory droplets when an infected person coughs, sneezes, or talks. It can also be transmitted via contact with contaminated surfaces, although this is less common. COVID-19 is characterized by a wide range of symptoms, from mild respiratory symptoms to severe pneumonia and acute respiratory distress syndrome (ARDS), which can be fatal. The virus’s highly contagious nature, coupled with the initial lack of immunity in the global population, led to widespread infection, overwhelming healthcare systems in many countries. COVID-19 has had a profound impact on global health, causing millions of deaths and long-term health complications in many survivors. The pandemic exposed vulnerabilities in healthcare systems, particularly in terms of preparedness, capacity, and resource allocation. Hospitals were often overwhelmed, with shortages of ventilators, personal protective equipment (PPE), and intensive care unit (ICU) beds. Additionally, the pandemic highlighted health disparities, as marginalized communities were disproportionately affected by the virus due to factors like limited access to healthcare, crowded living conditions, and pre-existing health conditions. COVID-19 significantly affected the dental practice parameters. In the present chapter we shall discuss dental practice before and after COVID-19.

Importance of understanding the impact on dental practices

The COVID-19 pandemic has had a transformative impact on healthcare systems worldwide, and dental practices have been particularly affected due to the unique nature of dental care. Understanding the impact of COVID-19 on dental practices is crucial for several reasons, as it directly influences public health, the dental industry, and the overall well-being of populations.

High-risk environment for transmission

Dental practices are inherently high-risk environments for the transmission of COVID-19. The nature of dental procedures, which often involve close contact with patients’ oral and respiratory secretions, generates aerosols that can carry viral particles. This puts both dental professionals and patients at a heightened risk of exposure to the virus. By understanding the impact of the pandemic on dental practices, we can develop and implement effective infection control measures to protect both healthcare workers and patients, reducing the risk of transmission within these settings.

Ensuring continuity of essential dental care

The pandemic disrupted routine dental care, leading to the postponement or cancellation of non-emergency procedures. This disruption had significant implications for oral health, as untreated dental issues can progress into more severe conditions, causing pain, infection, and even systemic health problems. Understanding the impact of COVID-19 on dental practices allows for the identification of strategies to maintain the continuity of essential dental care, even during public health crises. This includes prioritizing urgent care, adopting tele-dentistry, and developing protocols for safe in-person visits.

Financial and operational challenges

Dental practices faced substantial financial and operational challenges due to the pandemic. Temporary closures, reduced patient volumes, and the increased costs associated with enhanced infection control measures strained the financial viability of many practices, particularly small and independent ones. Understanding the economic impact on dental practices is important for developing support mechanisms, such as financial aid, grants, or policy changes, to ensure the sustainability of these businesses and the broader dental industry.

Impact on dental workforce and training

The pandemic also affected the dental workforce, leading to job losses, furloughs, and changes in the work environment. Dental professionals faced increased stress, burnout, and concerns about their safety, which impacted their mental health and job satisfaction. Additionally, dental education and training were disrupted, with schools and training programs shifting to online formats. Understanding the impact on the dental workforce is crucial for addressing these challenges, supporting the well-being of dental professionals, and ensuring the continuity of high-quality dental education and training.

Evolution of dental practice and innovation

COVID-19 has accelerated changes in the way dental care is delivered, leading to the adoption of new technologies and innovations. Tele-dentistry, for example, emerged as a vital tool for remote consultations and patient triage during the pandemic. Understanding the impact of the pandemic on dental practices can inform the evolution of dental care models, encouraging the integration of digital tools, enhancing patient safety, and improving the overall efficiency of dental services. This knowledge also fosters innovation in infection control, practice management, and patient care.

Public health implications

Oral health is closely linked to overall health, and disruptions in dental care can have broader public health implications. Poor oral health has been associated with a range of systemic conditions, including cardiovascular disease, diabetes, and respiratory infections. Understanding the impact of COVID-19 on dental practices helps to highlight the importance of oral health as a component of public health. It underscores the need for coordinated efforts to ensure that dental care is integrated into public health strategies, particularly during pandemics and other public health emergencies.

Pre-Pandemic Infection Control Protocols in Dental Settings

Before the COVID-19 pandemic, dental practices followed rigorous infection control protocols designed to prevent the transmission of infectious diseases between patients and dental healthcare providers. These protocols were based on guidelines provided by health organizations such as the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and various national dental associations. The primary goal of these protocols was to ensure a safe environment for both patients and staff, minimizing the risk of cross-contamination and infection.

Standard Precautions

Standard precautions, also known as universal precautions, were the foundation of infection control in dental settings. These precautions assumed that all patients could potentially be infectious, regardless of their health status or known diagnoses. Key components of standard precautions included:

• Hand Hygiene: Hand hygiene was one of the most critical aspects of infection control. Dental professionals were required to perform hand hygiene before and after contact with each patient, before donning and after removing gloves, and after touching any potentially contaminated surfaces. Hand hygiene could be performed using soap and water or alcohol-based hand rubs, depending on the circumstances.
• Personal Protective Equipment (PPE): Dental professionals routinely wore personal protective equipment to protect themselves and their patients from exposure to infectious agents. The standard PPE in dental settings included gloves, masks, protective eyewear (such as goggles or face shields), and gowns. These items provided barriers against splashes, sprays, and direct contact with blood, saliva, and other body fluids.
• Respiratory Hygiene/Cough Etiquette: Patients exhibiting signs of respiratory infections were advised to cover their mouths and noses with tissues or their elbows when coughing or sneezing. Dental practices also provided tissues and no-touch disposal bins in waiting areas to promote good respiratory hygiene.
• Safe Injection Practices: Safe injection practices were critical to preventing the transmission of bloodborne pathogens such as HIV, hepatitis B, and hepatitis C. This included using sterile needles and syringes for each injection, properly disposing of sharps in designated containers, and avoiding the reuse of single-use devices.
• Environmental Cleaning and Disinfection: Dental practices followed strict protocols for cleaning and disinfecting surfaces and equipment. High-touch surfaces such as dental chairs, countertops, and doorknobs were regularly cleaned with EPA-approved disinfectants. Non-critical equipment that came into contact with intact skin, such as blood pressure cuffs, was also disinfected between patients.

Sterilization and instrument reprocessing

Sterilization of dental instruments was a crucial component of infection control. Instruments that penetrated soft tissue or bone (critical instruments) or contacted mucous membranes (semi-critical instruments) were subjected to stringent sterilization procedures. The sterilization process involved several key steps:

• Cleaning: Instruments were first cleaned to remove debris, blood, and other organic matter. This was typically done using ultrasonic cleaners or manual scrubbing with detergent and water. Proper cleaning was essential because residual debris could interfere with the sterilization process.
• Packaging: After cleaning, instruments were dried and packaged in sterilization pouches or wraps. These packages were designed to maintain the sterility of the instruments until they were used.
• Sterilization: Packaged instruments were then sterilized using autoclaves, which applied steam under pressure to kill all microorganisms, including bacterial spores. Other sterilization methods included dry heat ovens, chemical vapor sterilizers, and gas sterilization with ethylene oxide. The choice of method depended on the type of instruments and materials being sterilized.
• Storage: Sterilized instruments were stored in a clean, dry environment to maintain their sterility until use. Practices were careful to monitor the integrity of sterilization packaging and to rotate stock to ensure that older sterilized items were used first.
• Monitoring and Validation: Dental practices were required to monitor the effectiveness of their sterilization procedures regularly. This included using biological indicators (spore tests) to verify that the sterilization process was effective in killing microbial spores. Chemical indicators, such as sterilization tape, were also used to confirm that the instruments had been exposed to the correct conditions during the sterilization process.

Management of Dental Unit Waterlines

Dental unit waterlines (DUWLs) could harbor biofilm, a thin layer of microorganisms that can pose a risk of infection if contaminated water is used during dental procedures. Pre-pandemic protocols for managing dental unit waterlines included:

• Flushing: Waterlines were flushed at the beginning of each day and between patients to reduce the microbial load. This involved running water through the lines for several minutes to clear any stagnant water and reduce the risk of biofilm formation.
• Use of waterline treatments: Various waterline treatments, such as chemical disinfectants or filters, were used to control biofilm and maintain the quality of water used in dental procedures. These treatments were regularly applied according to the manufacturer’s instructions.
• Water quality monitoring: Dental practices were required to monitor the quality of water used in dental procedures, ensuring it met the standards set by health authorities, typically less than 500 CFU/mL (colony-forming units per milliliter) of heterotrophic bacteria.

Patient management and workflow

Infection control also extended to how patients were managed within the dental practice to minimize the risk of cross-contamination:

• Screening for infectious diseases: Although not as prevalent as during the COVID-19 pandemic, patients were routinely screened for symptoms of infectious diseases, such as influenza, and were asked to reschedule appointments if they were unwell. This screening helped reduce the risk of transmitting infections in the dental office.
• Appointment scheduling: Practices often staggered appointments to minimize the number of patients in the waiting area at any given time. This reduced the potential for contact between patients and helped maintain a controlled environment.
• Use of barriers and single-use items: Disposable items, such as patient bibs, covers for light handles, and suction tips, were widely used to prevent cross-contamination. These items were discarded after a single use, ensuring that each patient received care in a clean environment.
• Waste management: Proper disposal of medical waste, including sharps, blood-soaked gauze, and used PPE, was essential to preventing the spread of infectious agents. Waste was segregated, labeled, and disposed of in accordance with local regulations to minimize the risk of exposure to healthcare workers and the community.

Immediate Effects of the Pandemic on Dental Practices

The onset of the COVID-19 pandemic in early 2020 led to widespread and immediate disruptions across various sectors, with dental practices being among the hardest hit within the healthcare industry. As the virus spread rapidly across the globe, dental practices faced unprecedented challenges that required swift and significant changes to their operations. The immediate effects of the pandemic on dental practices included closures, reduced services, financial strain, and the need to rapidly adapt to new safety protocols. These effects can be categorized into several key areas:

Mandatory closures and suspension of services

As COVID-19 cases surged, many countries implemented strict public health measures to curb the spread of the virus. These measures included lockdowns, social distancing mandates, and the temporary closure of non-essential businesses, which had a direct impact on dental practices.

Government-mandated closures: In many regions, dental practices were required to close their doors temporarily, except for emergency services. These closures were implemented to reduce the risk of virus transmission in a high-contact environment and to conserve personal protective equipment (PPE) for frontline healthcare workers in hospitals. As a result, routine dental care, including preventive and elective procedures, was halted.

Reduced operating hours: Even in areas where complete closure was not mandated, dental practices often reduced their operating hours or limited the number of patients they could see each day. This was done to minimize the number of people in the office at any given time, thereby reducing the risk of exposure for both patients and staff.

Limitation to Emergency-Only Services

During the initial phase of the pandemic, dental practices were advised or required to limit their services to urgent and emergency care only. This decision was made to minimize the potential spread of COVID-19 and to ensure that dental professionals could focus on treating conditions that, if left untreated, could lead to severe health consequences.

• Definition of dental emergencies: Emergency dental care was defined to include situations such as severe tooth pain, abscesses, trauma, and other conditions that required immediate attention to prevent further complications. Non-urgent procedures, such as routine cleanings, cosmetic dentistry, and elective surgeries, were deferred.
• Tele-dentistry for triage: To manage patient care while limiting in-person visits, many dental practices adopted tele-dentistry as a tool for triaging patients. Through virtual consultations, dental professionals could assess the urgency of a patient’s condition, provide guidance on managing symptoms, and determine whether an in-person visit was necessary.

After COVID-19 outbreak, guidelines and recommendations from health authorities (e.g., CDC, WHO, ADA)

In response to the COVID-19 pandemic, health authorities around the world issued a series of guidelines and recommendations to help dental practices manage the risks associated with the virus while continuing to provide essential care. Key organizations, including the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the American Dental Association (ADA), played crucial roles in disseminating these guidelines. These recommendations covered various aspects of dental practice, including infection control, patient management, and the use of personal protective equipment (PPE).

Centers for Disease Control and Prevention (CDC)

The CDC provided comprehensive guidelines to help dental practices minimize the risk of COVID-19 transmission within their facilities. These guidelines were regularly updated as new information about the virus became available. Key recommendations included,

Infection Control Protocols

Screening and Triage: The CDC recommended that dental practices screen patients for COVID-19 symptoms and exposure before their appointments. This included conducting pre-visit questionnaires and checking temperatures upon arrival. Patients with symptoms or recent exposure were advised to delay non-urgent dental care.

Enhanced Hand Hygiene

Dental professionals were instructed to follow stringent hand hygiene practices, including washing hands with soap and water for at least 20 seconds or using an alcohol-based hand sanitizer with at least 60% alcohol before and after patient interactions.

Use of PPE

The CDC emphasized the importance of wearing appropriate PPE, including N95 respirators or higher-level respirators, face shields, gowns, and gloves, particularly during aerosol-generating procedures. They also recommended that dental practices ensure an adequate supply of PPE to protect both staff and patients.

Aerosol management

To reduce the risk of airborne transmission, the CDC recommended the use of high-efficiency particulate air (HEPA) filtration systems, high-volume evacuators, and rubber dams to minimize aerosol production during procedures. They also advised limiting the use of ultrasonic scalers, air polishers, and other aerosol-generating devices whenever possible.

Environmental cleaning and disinfection

The CDC provided detailed guidance on cleaning and disinfecting dental operatories and common areas between patients. This included using EPA-approved disinfectants effective against SARS-CoV-2 and ensuring that frequently touched surfaces were cleaned regularly.

Patient management

Tele-dentistry: The CDC encouraged the use of tele-dentistry for initial patient assessments, triage, and follow-up care. This helped reduce the number of in-person visits and limited the potential for virus exposure.

Staggered Appointments: To maintain social distancing, the CDC recommended staggering patient appointments and reducing the number of patients in the office at any given time. Practices were also advised to implement contactless check-in and payment procedures.

Physical Modifications: The CDC suggested making physical modifications to dental offices, such as installing physical barriers at reception areas, spacing out seating in waiting rooms, and placing visual markers to remind patients of social distancing requirements.

Emergency-Only Services: At the height of the pandemic, the CDC advised dental practices to limit care to emergency and urgent cases only. This included treatment for severe dental pain, infections, and trauma. Routine and elective procedures were deferred until transmission rates declined.

World Health Organization (WHO) recommendations

The WHO issued global recommendations to guide dental practices in maintaining safety during the COVID-19 pandemic. These recommendations were particularly important for countries with varying levels of healthcare resources and infrastructure.

Risk Assessment

COVID-19 Risk Levels: The WHO recommended that dental practices conduct a thorough risk assessment before providing care, taking into account the local transmission levels of COVID-19. In areas with high transmission, non-essential dental care was advised to be postponed.

Staff Health Monitoring: The WHO emphasized the importance of regularly monitoring the health of dental staff, including checking for COVID-19 symptoms and ensuring that any symptomatic individuals stayed home until they were cleared to return to work.

Infection prevention and control (IPC):

Standard precautions

The WHO reinforced the importance of standard infection prevention and control measures, such as hand hygiene, the use of PPE, and safe injection practices, as the baseline for preventing the spread of COVID-19 in dental settings.

Enhanced PPE use

Similar to the CDC, the WHO recommended the use of enhanced PPE, particularly during aerosol-generating procedures. This included respirators, eye protection, and full-body gowns or aprons.

Sterilization and disinfection

The WHO provided guidelines on the sterilization and disinfection of dental instruments and equipment, highlighting the need for rigorous adherence to established protocols to prevent contamination.

Patient Flow and Management

Appointment Scheduling

The WHO advised dental practices to manage patient flow carefully by scheduling appointments to reduce waiting times and avoid crowding. They also recommended the use of tele-dentistry for consultations when possible.

Minimizing Aerosol Generation

The WHO suggested using rubber dams, high-volume evacuators, and pre-procedural mouth rinses to reduce aerosol production during dental procedures. They also advised practices to ensure adequate ventilation in treatment areas to dilute any airborne particles.

Communication and Education

Patient communication

The WHO emphasized the importance of clear communication with patients regarding the changes in dental practice operations due to COVID-19. Patients were to be informed about the precautions being taken to protect their health and safety.

Staff training

The WHO recommended ongoing training for dental staff on the latest IPC measures, proper use of PPE, and the protocols for managing suspected or confirmed COVID-19 cases in the dental setting.

American Dental Association (ADA) recommendations

The ADA provided specific guidelines and resources tailored to dental practices in the United States, addressing both clinical and operational challenges posed by the pandemic.

Return to work toolkit

Phased Reopening: The ADA developed a “Return to Work Toolkit” that provided a roadmap for dental practices to resume operations safely. This toolkit included checklists, patient communication templates, and protocols for phased reopening based on local public health conditions.

Office Preparation: The ADA recommended that dental practices prepare their offices for reopening by conducting a thorough cleaning, ensuring the availability of PPE, and making necessary modifications to office layout and patient flow to comply with social distancing guidelines.

Pre-Appointment Screening: The ADA advised dental practices to implement pre-appointment screening for COVID-19 symptoms and exposure. This included phone or online questionnaires to assess patients’ health status before they arrived at the office.

Infection Control Guidelines

Enhanced PPE Use: The ADA supported the use of enhanced PPE, including N95 respirators, face shields, gowns, and gloves, particularly for aerosol-generating procedures. They also provided guidance on the proper donning and doffing of PPE to minimize the risk of contamination.

Aerosol Mitigation Strategies: The ADA emphasized the importance of minimizing aerosol production in dental procedures. This included the use of high-volume evacuation, rubber dams, and pre-procedural rinses, as well as considering the installation of air purifiers with HEPA filters in treatment rooms.

Financial and Operational Support

Economic Relief Resources: Recognizing the financial impact of the pandemic on dental practices, the ADA provided resources and guidance on accessing federal economic relief programs, such as the Paycheck Protection Program (PPP) and Economic Injury Disaster Loans (EIDL).

Practice Management: The ADA offered practice management advice on maintaining patient relationships, adjusting business models to include tele-dentistry, and managing staff during the pandemic. This included guidance on staffing decisions, such as furloughs and layoffs, as well as strategies for maintaining financial stability.

Lessons learned from the pandemic

The COVID-19 pandemic has profoundly impacted the dental profession, bringing to light a range of challenges and opportunities for improvement. As the dental community continues to navigate the ongoing effects of the pandemic, several key lessons have emerged that will shape the future of dental practice. These lessons extend beyond infection control and patient management, encompassing broader issues such as preparedness, resilience, and the integration of technology. Below are some of the most significant lessons learned from the pandemic:

Importance of preparedness and flexibility

The COVID-19 pandemic underscored the critical importance of preparedness and the ability to quickly adapt to unforeseen challenges. Dental practices that had contingency plans and were able to pivot rapidly fared better during the crisis.

Emergency preparedness

The pandemic highlighted the need for dental practices to have comprehensive emergency preparedness plans in place. This includes not only infection control protocols but also strategies for managing sudden closures, supply chain disruptions, and financial instability. Practices that had emergency response plans were better equipped to implement necessary changes quickly and efficiently.

Flexibility in operations

The ability to adapt to changing circumstances proved essential for dental practices during the pandemic. Flexibility in scheduling, patient management, and service delivery allowed practices to continue providing care despite the challenges posed by COVID-19. For example, practices that were able to quickly adopt tele-dentistry and modify their office layouts for social distancing were better positioned to maintain operations.

Enhanced infection control and safety measures

The pandemic has permanently altered the approach to infection control in dental settings, with many of the enhanced safety measures implemented during COVID-19 likely to become standard practice moving forward.

• Heightened Awareness of Aerosol Risks: The pandemic brought increased awareness of the risks associated with aerosols generated during dental procedures. This has led to a greater emphasis on aerosol management strategies, such as the use of high-volume evacuation, rubber dams, and improved ventilation systems. Dental practices have also recognized the importance of investing in advanced air filtration technologies to reduce the risk of airborne transmission.
• PPE as a Standard of Care: The widespread adoption of enhanced PPE, including N95 respirators, face shields, and gowns, has set a new standard for infection control in dental settings. While the use of such PPE was previously limited to specific high-risk procedures, it has now become more commonplace, with many practices likely to continue these protocols to protect both patients and staff.
• Increased Frequency of Environmental Cleaning: The rigorous cleaning and disinfection protocols implemented during the pandemic have underscored the importance of maintaining a clean and sanitized environment in dental practices. Regular disinfection of surfaces, equipment, and common areas has become a routine part of infection control, contributing to a safer clinical environment.

The role of technology in enhancing care delivery

The pandemic accelerated the adoption of technology in dental practices, highlighting its potential to enhance care delivery, improve patient access, and streamline operations.

• Tele-dentistry as a viable option: The rapid adoption of tele-dentistry during the pandemic demonstrated its effectiveness as a tool for providing remote consultations, triaging patients, and delivering follow-up care. Tele-dentistry has the potential to improve access to dental care, particularly for patients in remote or underserved areas, and to reduce the burden on in-office appointments. Moving forward, tele-dentistry is likely to remain a valuable component of dental care delivery.
• Digital patient management: The use of digital tools for patient management, including electronic health records (EHR), online appointment scheduling, and contactless payment systems, became more prevalent during the pandemic. These technologies not only improved efficiency but also enhanced patient safety by reducing the need for in-person interactions. The integration of digital tools is expected to continue, driving greater convenience and efficiency in dental practice management.
• Remote education and training: The pandemic also highlighted the potential of remote education and training for dental professionals. Online continuing education courses, virtual conferences, and remote collaboration tools allowed dental professionals to stay informed and connected during the pandemic. This shift toward remote learning is likely to persist, offering greater flexibility and access to educational resources.

Conclusion

The immediate effects of the COVID-19 pandemic on dental practices were profound, leading to widespread closures, limitations to emergency-only services, financial strain, and disruptions in patient care. Dental practices were forced to quickly adapt to new infection control protocols and navigate the economic challenges posed by the pandemic. These effects not only impacted the dental industry but also had broader implications for public health, as access to essential oral healthcare was significantly disrupted. Understanding these immediate effects is crucial for addressing the ongoing challenges faced by dental practices and ensuring the resilience of the dental industry in the face of future public health crises.

References

References are available in the hardcopy of the website “Periobasics: A Textbook of Periodontics and Implantology”.