Published August 7, 2020
The outbreak of coronavirus disease 2019 (COVID-19) effectively shut down approximately 198,000 active dentists and dental specialists in the USA.1-3 As individual states authorize the resumption of routine dental care,4 discussion has centered on how to provide safe oral healthcare,5-7 care that has been defined in a previous primer,8 given the nature of the virus and how easily it may be dispersed during common dental procedures. However, the time has come to look beyond treating urgent dental care needs and start planning for resumption of routine dental care and finding creative ways to care for dental patients who are reluctant to come to the dental office for the foreseeable future. This will be a challenging task given the uncertainty surrounding the timeline for resolution of this pandemic.
The virus that causes COVID-19, SARS-CoV-2, is profusely present in nasopharyngeal and salivary secretions of patients infected with SARS-CoV-2,9-11 and is believed to be spread primarily through respiratory droplets, as well as aerosols and fomites.12 Importantly, emerging evidence shows that normal breathing and talking can produce small droplets that are subject to aerosol transport and that aerosolized SARS-CoV-2 particles can remain suspended in the air for several hours,13-16 although it is unclear how much aerosol spread contributes to viral transmission.15,17 The widespread transmission of SARS-CoV-2 in many communities,18 the potential for infected individuals who are pre-symptomatic or asymptomatic to transmit the virus to others, and the unique nature of dental interventions with close proximity of the provider to the patient’s mouth and throat, all contribute to the high risk for dental personnel teams becoming exposed and transmitting the virus to other patients or staff. Some dental procedures may lead to aerosol generation, further increasing transmission risk to dental providers or future patients through direct inhalation or contact with contaminated surfaces.
The Patient Safety Challenges
Infection control and prevention in the dental office setting
Dental professionals are very familiar with occupational health issues and corresponding risk assessments in order to reduce risk,19 and with applying Standard Precautions for minimizing spread of infection directly or through cross-contamination.20 Preventing the spread of SARS-CoV-2 requires new management strategies that may differ from those used to manage other diseases. COVID-19’s incubation period can range from 2-14 days (median, 4 days),21 and, while the virus is known to be highly transmissible when patients are most symptomatic, transmission can occur before any symptoms are apparent.22 Additionally, the majority of people infected with SARS-CoV-2 may have no symptoms or symptoms that resemble seasonal allergies or influenza, contributing to a significant number of undiagnosed cases.23 Hence, even asymptomatic dental patients should be considered as potential carriers and therefore it is recommended to implement a routine screening process for both patients and staff, to ensure that both symptomatic and recently exposed individuals stay home for the safety of all patients and dental team members.24
Current guidelines (as of May, 29, 2020) recommend that elective care for dental patients with confirmed or suspected COVID-19 be deferred until the patient meets criteria for discontinuation of home isolation.25 For patients with confirmed or suspected COVID-19 who need to receive emergency or urgent dental care, various treatment guidelines have been developed by the Centers for Disease Control and Prevention (CDC),5 the American Dental Association (ADA),26 the Occupational Safety and Health Administration (OSHA),27 and others to prevent spread of infection. Dental care providers are advised to:
- If possible, perform procedures in a negative pressure room, (airborne infection isolation room or AIIR) for aerosol-generating dental procedures.5, 26, 28
- Follow standard, contact, and airborne precautions including hand hygiene practice.29-31
- Consider taking extraoral radiographs instead of intraoral (e.g. panoramic radiography) to avoid gag reflex.29
- Limit the number of dental healthcare providers (DHCP) present during the procedure to only those essential for patient care and procedure support. Visitors should be limited to those who are necessary.5, 27
- Use a dental hand-piece with anti-retraction function, four-handed dentistry, high evacuation suction and rubber dams to minimize droplet splatter and aerosol generation.5, 26, 29
- Minimize the use of ultrasonic instruments, high-speed handpieces, and 3-way syringes.
- Perform endodontic procedures with dilute (1%) solutions of sodium hypochlorite to extend supplies without adverse effects on outcomes.32
- Use resorbable sutures (i.e. sutures that last 3 to 5 days in the oral cavity) to eliminate the need for a follow up appointment.29
- Disinfect surfaces with EPA-approved chemicals and maintain a dry environment.5, 27, 33, 34
- Wear an N95 or equivalent or higher-level respirator such as a disposable filtering facepiece respirator, a powered air-purifying respirator, or an elastomeric respirator; eye protection (e.g. goggles, reusable face shields); gloves; and a gown.5, 27, 28
Using a negative pressure room may create challenges as most if not all private practice dental offices lack AIIRs and larger dental organizations may have dental operatories that are clustered in open spaces without physical barriers. As an alternative, CDC is currently recommending placing a portable HEPA air filtration unit within the vicinity of the patient’s chair (but not behind the DHCP) while the patient is actively undergoing, and immediately following, a potentially aerosol-generating procedure.5
Access for patients needing oral healthcare
Delayed dental care has a variety of consequences, whether it is due to dental office closures, reluctance to seek care during a pandemic, loss of employer-sponsored dental insurance coverage, or other factors.35 Routine dental visits are opportunities to provide preventive oral health care (e.g., fluoride treatment and sealants) and to identify oral manifestations of systemic disease that might otherwise be missed.35 A lack of access to routine dental care can also lead to untreated tooth decay or other infections, leaving people with no viable option other than visiting a hospital emergency department, where treatment is costly and can disrupt more urgent needs, especially during a pandemic.36 In addition, many emergency departments are not staffed or equipped to provide definitive dental treatment and instead only provide patients with temporizing measures such as prescriptions for short-term treatment of pain and/or infection until definitive care can be provided elsewhere.37, 38
Federally qualified health centers (FQHCs) have a particularly important role in providing dental services to underserved populations at high risk of unmet oral health care needs; about 6.4 million US residents received dental care at an FQHC in 2018.39 With FQHC dental programs already operating on limited margins, some have responded to COVID-19 by redeploying dental staff to frontline COVID-19 testing or triage roles or furloughing staff, further decreasing access to care.40 In addition, during budget shortfalls, dental benefits are often among the first services cut from state Medicaid programs. In the 2008 recession, 19 states removed or limited adult dental services from their Medicaid programs. Loss of dental coverage among low-income patients resulted in lower dental care utilization and higher emergency department utilization for dental problems.41 FQHCs are often highly dependent on Medicaid reimbursement, so reduced Medicaid coverage for dental care decreases their ability to provide dental services.40
Re-configuring Dental Practice
Due to the COVID-19 pandemic, new challenges may prevent the return to routine delivery of non-emergent care. Up-to-date recommendations for communications, protocols, and physical measures must be in place to resume safe patient care. For example, interim guidance from the ADA includes:42
- Sending patients reassurance letters;
- Implementing a pre-appointment screening process via text, telephone, or email to ensure that patients with symptoms consistent with COVID-19 – or recent exposure to infected individuals - do not travel to the dental office;
- Expanding the in-office registration process to screen out patients with symptoms consistent with COVID-19, or who have been exposed to or recently tested for SARS-CoV-2; to provide and require proper use of a face mask; to check patients’ temperature (<100.4°F) with a thermometer; and to provide wipes or materials to clean pens, clipboards, counters, phones, keyboards, light switches, and other “high touch” surfaces;
- Extending time between patients, as necessary, to allow for proper cleaning and decontamination of examination rooms;
- Extensive preparation strategies for the physical office and staff to prepare the environment and familiarize the staff with new policies and procedures to reduce the risk of transmission of SARS-CoV-2;
- Implementing a chairside checklist to prepare operatories;
- Staff protection strategies that may include recommendations for in-office clothing (emphasizing that clinical attire should only be worn in the dental practice, not back to staff members’ homes or other community settings, to prevent cross contamination of SARS-Cov-2), special guidance for staff who are pregnant or have other factors that increase the risk of severe COVID-19 disease, and a COVID-19 daily screening log for dental team members to use before entering the practice;
- Limiting the number of patients in the waiting room at the same time; as part of physical distancing;43 and
- Using tele-dentistry such as real-time video consultations to determine if a patient’s oral health needs can be handled remotely.
During the shutdown, some dentists have setup telehealth services44 to provide virtual care to their patients.19 Tele-dentistry is “a combination of telecommunications and dentistry, involving the exchange of clinical information and images over remote distances for dental consultation and treatment planning”45 and includes the use of phone, photos and videos to facilitate delivery of oral healthcare and oral health education services.46 To engage in tele-dentistry, the patient must have a smartphone and Internet access. For the dentist, a cloud-based tele-dentistry platform can support both real-time streaming of videos and “store and forward” of clinical data collected, including data from the electronic health record (EHR) and photos received from the patient. Such a platform is able to aggregate all data allowing the dentist to remotely evaluate the patient and develop recommendations.47 Services provided as part of a tele-dentistry visit may include problem-focused and urgent care evaluations (e.g., acute swelling/pain) with pharmacologic management; follow-up care after emergency visits; and virtually triaging of patients for COVID-19 symptoms.
Tele-dentistry has not historically been widely adopted by the dental profession due to limits on reimbursement, state regulations and the perception that dental care requires in-person visits. Current studies in tele-dentistry mainly focus on how tele-dentistry can be used in public health;48, 49 in various settings;50-53 for specific conditions;52-58 training;59-61 address access issues;62-64 or costs.65-67 Two small oral medicine studies offer insight how tele-dentistry can be used successfully by dental professionals.68,69 Tele-dentistry has multiple models, one of which uses a dental hygienist who sets up a temporary dental clinic, e.g. in a school or senior center. During the pandemic, however, dentists have resorted to the model that does not require an in-person intermediary. On April 14, 2020, the ADA disseminated interim guidelines on billing and coding for tele-dentistry visits in an effort to facilitate the use of tele-dentistry during the pandemic.70 While the pandemic has necessitated its use, more research is needed to help determine the technology needs, criteria for reimbursement, and types of oral healthcare problems that can be safely addressed using tele-dentistry.
Although not explicitly mandated in the new guidelines, providing safe dental care during the COVID-19 pandemic may require dentists to change their workflows patterns,42,71 or re-configure their clinic layouts besides ensuring adequate additional personal protective equipment (PPE) supplies. The CDC provides clear information on PPE and related acquisition issues.72 These changes may lead to increased costs (see “Federal Guidance and Resources for the Dental Community” section for possible reimbursement). Additionally, wearing PPE can be uncomfortable and may be physically challenging to do certain procedures in the required PPE.73 Providers may also be challenged to balance a significant backlog of patients who were in mid-treatment when state or local orders mandated closure and patients with new, unmet urgent needs, and as a result, may consider extending their practice hours. These conditions may create several challenges, including the desire to limit exposure to patients, fatigue, burnout, and pressure to reduce procedure times, which may set the stage for increased errors in dental practice. Knowledge-based active errors (e.g., misdiagnosis), rule-based active errors (e.g., forgetting instructions), or skill-based active errors (e.g., leaving cement in the sulcus), can all jeopardize patient safety and quality of care.74 Managing necessary deviations from well-rehearsed practice, while under additional budgetary pressures, stress and time constraints, may increase the risk of patient safety failures during dental care.
Federal and International Guidance and Resources for the Dental Community
CDC regularly updates its infection control guidance for COVID-19 including precautions to follow when performing aerosol generating procedures and guidance on wearing PPE.28 In mid-May, the CDC published updated interim infection prevention and control guidance for the dental setting outlining recommendations for resuming non-emergency dental care and facility and equipment recommendations, as outlined above. These recommendations were updated in August 2020,5 along with FAQs of more general interest.75 As of August 2020, CDC recommends to “provide dental treatment only after you have assessed the patient and considered both the risk to dental healthcare personnel and patients of healthcare-associated SARS-CoV-2 transmission,”5 while the World Health Organization (WHO) “advises that routine non-essential oral health care… be delayed until there has been sufficient reduction in COVID-19 transmission rates from community transmission to cluster cases or according to recommendations at national, sub-national, or local level.”76 With respect to tele-dentistry, CMS has offered guidance regarding tele-health for medical healthcare providers (HCPs) that should be helpful for dental HCPs although not specified as such by CMS, along with a separate toolkit for patients.77 CMS has also provided specific information on Medicaid and Children’s Health Insurance Program (CHIP) benefits regarding telehealth for dental patients.78 OSHA published interim guidance for the dental provider, as outlined above, supplementing the general interim guidance for HCP at increased risk of occupational exposure to COVID-19.27 The Health Resources & Services Administration’s (HRSA) Telehealth Resource Centers provide general technical assistance information on telehealth.79 As evidence changes frequently, dental practices should check regularly for updates to all federal guidance documents.
Professional Organization Resources
The ADA has published extensive and freely available guidance for dental providers related to COVID-19.4, 26, 29, 42 In addition, the ADA has expressed respectful but strong disagreement “with the World Health Organization’s (WHO) recommendation to delay routine dental care in certain situations due to COVID-19,”80 favoring a risk-based approach to postpone elective procedures, surgeries, and non-urgent dental visits only "for those parts of the country where COVID-19 infection rates are accelerating or peaking."81 A series of practical resources are available on the ADA website including: guidance on coding and billing when using tele-dentistry;70 a policy statement on tele-health;82 guidance on minimizing risk associated with COVID-19;29 flowcharts detailing processes to minimize COVID-19 transmission when treating dental emergencies;26 and a toolkit on reopening dental offices.42 Additional professional organizations and individual State governments are similarly providing resources such as frequent updates, FAQs and Resources, Return to Practice roadmaps, and advice about how to access monies set aside for small businesses as part of the original $2 trillion CARES act and the second $480 billion relief package. The American Dental Education Association’s website provides COVID-19-specific resources for dental educators.83 The Academy of General Dentistry (AGD) provides COVID-19 resources especially for general dentists including return to work guidance, small business assistance information, and regulatory resources.84 The American Dental Hygienists’ Association offers interim guidelines related to dental hygiene equipment, monitoring and managing dental HCPs, hygiene, office protocols, patient preparation, avoiding aerosol-generating procedures, and use of PPE.85
The COVID-19 pandemic has impacted how dental care can be safety delivered in the short term, and likely will stimulate permanent changes in how dental care is delivered. The profession will need to consider a number of unanswered questions; for example, whether the workflow and layout of dental clinics should be permanently reorganized, and whether expanded PPE is warranted for care of all dental patients as part of Standard Precautions. Dental care providers should be prepared to assist patients in understanding their dental insurance benefits, which may have changed due to the pandemic. The COVID-19 pandemic may also hasten the adoption of innovative dental workforce models, including dental therapists who complete at least 3 years of academic training and provide a limited scope of treatment, such as prevention, fillings, and treatment for periodontal disease, in collaboration with a dentist. Dental therapists have been found to reduce overall dental costs and expand access in rural and tribal areas.86 In a recovering economy, the lower cost of dental therapists may foster their adoption or more independent scope of practice.
The COVID-19 pandemic presents several opportunities for dental researchers to focus on key issues. Important research priorities may include estimating the costs and benefits of expanded PPE use (and other changes in dental practice workflows), developing and testing innovative approaches to minimize aerosol generation during dental procedures, testing and validating tele-dentistry models, and evaluating alternative dental workforce models, such as dental therapists.
Elsbeth Kalenderian, DDS, MPH, PhD
School of Dentistry
University of California at San Francisco
Yan Xiao, PhD, MS
College of Nursing and Health Innovation
University of Texas at Arlington
Heiko Spallek, DMD, PhD, MSBA (CIS)
School of Dentistry
University of Sydney
Amy Franklin, PhD
University of Texas Health Science Center at Houston
Gregory Olsen, DDS, MSc
University of Texas Health Science Center at Houston
Muhammad F. Walji, PhD
University of Texas Health Science Center at Houston
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