American Dentistry: Essential Health Care

Family rituals are comforting, and I recall our annual two-week vacation on Long Beach Island. It was always the same, from dining out at our favorite seafood restaurants to spending the entire day baking our bodies in the sun on the pure white sandy beaches. We rubbed baby oil into our skin and could feel it sizzle. Routine dentistry is a familiar American ritual, too, just like beach excursions or wearing blue jeans. Six month checkups are the norm for many Americans and we consider it essential healthcare.

On August 12, 2020, the American Dental Association (ADA) published the following statement: “The ADA respectfully yet strongly disagrees with the World Health Organization’s (WHO) recommendations to postpone ‘routine’ dental care in certain situations due to COVID-19”.¹

ADA President Chad P. Gehani, DDS, reasons that oral health can affect systemic health and he emphasizes the ADA position that dental care is essential healthcare. Earlier in the year (March 2020), the ADA urged dentists to postpone all but urgent and emergency dental care and their statement indicates it was done to “ further understand the disease, consider its effects on dental patients, dental professionals and the greater community.”¹ Since late February 2020, the Centers for Disease Control and Prevention (CDC) and the ADA began issuing interim guidance for dental professionals related to COVID-19 which is ongoing as we learn more about the pandemic.¹

Background Information on WHO

The WHO began as an 1851 International Sanitary Conference in Paris, France, in response to the cholera epidemics in 1830 and 1847 which killed tens of thousands of people in Europe. Due to political differences, little was accomplished at the time and the cause of cholera was unknown but it was the first step in the formation of an international cooperation for disease prevention and control.² Examples of WHO activities over the years include small pox eradication and mass campaigns against yaws, endemic syphilis, leprosy and trachoma. The WHO is known for helping to control a major cholera pandemic in Asia and the Western Pacific and the large epidemic of yellow fever in Africa.² The WHO has always been involved in wide-ranging disease prevention and control efforts worldwide and has scored some very notable public health successes including the near-eradication of polio, and the reduction of tuberculosis and measles through vaccination programs. In 1958 when approximately 2 million people were dying of smallpox every year, the WHO was able to announce in 1979 that small pox had been eradicated.²

What does essential healthcare mean during a worldwide pandemic?

The ADA has stated the following on their website (www.ada.org): Dentistry is essential healthcare. What does that mean and why does it clash with the new WHO guidance that non-essential oral healthcare should be delayed? I enjoy telling my patients that an infection-free mouth is an achievable and worthwhile personal goal that leads to improved oral health, well-being and quality of life. I don’t overplay the oral/systemic link hype because most of the links (correlations) are NOT cause/effect but I do believe that dental professionals have worked very hard to make diagnostic, preventive and therapeutic care a high priority for common oral diseases like dental caries and periodontitis. Unfortunately, financial pressure has forced many dental practices to place an extra burden on clinicians, in order to keep their businesses going. We must be careful not to condemn the owners of those practices for focusing more on profit: they are simply trying to sustain a business which, by the way, contributes significantly to the health of the community at large. It surely must be possible to find ways to continue the provision of comprehensive dental care, even in the midst of a viral pandemic but many procedures will require extra time and patience on the part of the entire dental team. What has changed is disruption in the “way things were” and the willingness to adapt to a “new normal”. The WHO is merely giving us guidance, and it is based on scientific evidence and public health expertise and research, past and present. Their role is to release guidelines to help countries to maintain essential health services during the COVID-19 pandemic. They help countries navigate through various challenges with updated operational planning guidelines.

Why is it necessary to update operational planning guidelines in healthcare during a pandemic? History has shown us that without balancing the demands of COVID-19 while maintaining essential healthcare delivery, there is a risk of system collapse.³ For example, during the 2014-2015 Ebola outbreak, number of deaths caused by measles, malaria, HIV/AIDS and tuberculosis actually exceeded deaths by Ebola.³ The WHO helps countries identify essential services and make strategic shifts to insure that limited resources provide maximum benefit for the population.³ Emergency health conditions in dentistry are considered essential services which are similar to essential services in medicine like routine vaccinations, reproductive health services, emergency health conditions and mental health conditions.³

WHO definition of essential oral health services during the COVID-19 pandemic (updated 8/3/20)

Guidance from the WHO during this pandemic is subject to change as new information becomes available. The WHO gives high priority to the effective prevention of oral problems and self-care. It is recommended that patients be given advice through remote consultation or social media channels on maintaining good oral hygiene.⁴ The report focuses on how transmission of the SARS-CoV-2 virus occurs (the virus that causes COVID-19), and is similar to CDC guidance andupdates. The WHO emphasizes the high risk of oral health care teams being infected with SARS-CoV-2 or passing the infection to patients.⁴ Guidance includes screening and triaging, infection control, facility and equipment hazards, acceptable/unacceptable procedures based on community spread, sterilization and disinfection, infection control and prevention, ventilation, facility and equipment, sterilization and disinfection and evidence-based PPE recommendations.⁴

Here’s where the ADA and the WHO guidance differ. The WHO is advising against routine non-essential oral health care at this time—which includes oral health check-ups, dental cleanings, preventive care and esthetic procedures. Their guidance recommends delaying routine care until there has been sufficient reduction in COVID-19 transmission rates from community transmission to cluster cases or according to official recommendations at national, sub-national or local level.⁴

Guidance applies to esthetic dental treatments but urgent or emergency oral health care interventions are permitted.⁴ In United States or local areas with high COVID-19 morbidity and mortality, the CDC has issued community mitigation strategies to reduce or prevent transmission.⁵ If you are working in an area with widespread community transmission, you will quite possibly be at much higher risk for COVID-19 infection and you might not even know it. Guidance in high risk areas includes minimizing and employing minimally invasive procedures like hand scaling as a priority and wearing appropriate personal protective equipment (PPE). Discarding respirators, surgical masks, gowns and gloves after patient is mentioned along with cleaning and disinfecting re-usable eye protection and face shields prior to re-use.⁴ Since there are no standard or evidence-based methods for reprocessing masks or respirators, the WHO recommends reprocessing only when there is a critical PPE shortage.⁴

New research by aerosol scientists and virologists have now confirmed the presence of infectious virus in the air. These floating respiratory droplets (aerosols) contain live virus and not just fragments of genetic material.⁶ A research team at the University of Florida was successful in isolating live virus from aerosols collected at a distance of 7 to 16 feet from patients hospitalized with COVID-19- farther than the 6 feet recommended in social distancing guidelines.⁶ This is the first time scientists were able to grow this virus from the air. The researchers used pure water vapor to enlarge the aerosols enough that they could be collected easily from the air. The equipment used to capture the aerosols immediately transferred them to a liquid rich in salts, sugar and protein, which preserved the pathogen.6 More studies of this nature need to be done in order to replicate the findings of this study but many scientists are calling this new study results a “smoking gun”.⁶

Case identification, isolation, testing, contact tracing and quarantine are critical activities to reduce transmission and control the epidemic and these activities are relatively new to dentistry. Part of a COVID-19 dental practice prevention plan should include coordination with local or state health departments with logistics to support contact tracing teams and a system to collate, compile and analyze data.⁷ There are new digital tools that can assist with healthcare worker contact tracing and exposure investigation. The Mayo Clinic is in process of implementing one of those tools electronically as part of the electronic medical record.⁸ According to the Mayo Clinic, instead of taking days to identify clinicians or patients who are at-risk, the tool can identify COVID-19 within hours.⁸

Traditionally, the U.S. has been a shining light in dental infection control and prevention, leading the way and setting an example around the globe. Let’s work with our health departments and professional associations to make sure we are slowing the spread of COVID-19 by employing mitigation strategies and contact tracing if an exposure occurs in the dental practice. Digital tools are needed in dentistry to speed up contact tracing and testing and limit the spread of coronavirus. Pay attention to precautions for airborne transmission and improved ventilation even though we don’t yet have evidence-based strategies on aerosol containment in dental operatories.

References

1. https://www.ada.org/en/press-room/news-releases/2020-archives/august/american-dental-association-dentistry-is-essential-healthcare?utm_source=adaorg&utm_medium=covidhome&utm_content=response-WHO&utm_campaign=covid-19

2. https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(02)11244-X.pdf

3. https://www.who.int/news-room/detail/30-03-2020-who-releases-guidelines-to-help-countries-maintain-essential-health-services-during-the-covid-19-pandemic

4. https://www.who.int/publications/i/item/who-2019-nCoV-oral-health-2020.1

5. https://www.cdc.gov/coronavirus/2019-ncov/community/community-mitigation.html

6. https://www.courant.com/nation-world/ct-nw-nyt-coronavirus-hospital-air-20200811-2fruaob6gvdpfodmph6tcvhpq4-story.html

7. https://www.who.int/publications/i/item/contact-tracing-in-the-context-of-covid-19

8. https://ehrintelligence.com/news/mayo-clinic-ehr-tool-runs-contact-tracing-among-hospital-staff