Hygiene in the Age of COVID: What to Expect in the New Normal

We have been through a lot the past year as a nation. We can see the light at the end of the pandemic tunnel as vaccines roll out across the country, and that light is shining on a new normal for the dental hygienist. What can we expect as we get back to business as usual?

JoAnn Gurenlian, RDH, MS, PhD, AFAAOM, is a professor and the graduate program director for Idaho State University and the American Dental Hygienists’ Association's (ADHA) Return to Work chair. Gurenlian appreciates how the pandemic necessitated ramping up safety measures in practice. While hygienists have always been diligent about adapting to improved safety measures, hygienists now provide a higher safety level in their approach, consistent with national guidelines.

"So even though we have this pandemic, and it's extremely serious, and patients may have felt reluctant to come to a dental practice setting, they should feel assured that we are putting forth every possible effort to ensure we protect their health and safety," Gurenlian says. "That is a win all the way around."

Katrina Sanders, RDH, a practicing dental hygienist, dental hygiene educator, and international speaker, says the most apparent safety changes are the layered approaches hygienists take to protect their patients and themselves. Sanders thinks the emphasis on infection control will have lasting implications for hygienists.

"Many of us have known for a long time that we should be wearing appropriate PPE [personal protective equipment] and using high-volume evacuation (HVE) with our aerosol-generating procedures. We shouldn't be leaving the office in the same scrubs that we treated our patient in to go to the grocery store," Sanders says. "We acknowledge that these are things that we've known we've needed to do, and now we have been pushed to action."

Tina Clarke, RDH, MEd, an instructor at Lane Community College in Eugene, Oregon, and owner of Teacher Tina RDH, has perspective as a practicing clinician and as a dental hygiene educator during the coronavirus 2019 (COVID-19) pandemic. Like Sanders, she has advocated for HVE and face shield usage every time hygienists use ultrasonic device instrumentation for years. However, she said, most people thought these infection control precautions were something you did only in school, not in a real-life operatory. She also appreciates the widespread adoption of infection control measures over the past year.

"For me, it's like people are finally listening and understanding the value behind it," Clarke says.

Kim Miller, RDH, BSDH, an international speaker and part of the Inspired Hygiene coaching team, agrees that the pandemic changed the perception about dental care and its essential nature to health and wellness of the population at-large. Many hygienists are experiencing how critical the care they provide to patients is—and what happens when patients don't receive that care.

"Their patients haven't been in; they've missed their recalls. Some patients let their dentistry go, and it caused problems for people, like periodontal infection and restorative issues," Miller explains. "That is probably one of the good things that came out of this pandemic. Not only did we weather the storm and step up to the plate as dental professionals, but the population has seen that taking care of your teeth and gums is essential to a person's health and wellness."

Gurenlian agrees that the pandemic brought into focus the critical nature of the care hygienists provide, as well as the history-taking they do. These histories tie into a growing movement to provide care for the total health of the patient. Gurenlian also sees a future where dental practices could administer all types of vaccines, not just for COVID-19. Patients could go to their medical provider, pharmacy, or dental office for their vaccines. Gurenlian thinks this capability would help patients see that dental care providers are health care providers.

"That's a big win, a huge win, and a positive outcome of a very serious infection we've been facing," Gurenlian says.

Moreover, the changing perception can help hygienists persuade patients to get the care they need, even if it is more often than every six months. Sanders says hygienists have the opportunity to be educators coming out of the pandemic.

"There's not a single piece of research out there that tells us we should be seeing patients every six months. Rather, we need to look at the patient's risk, their level of disease, and we should be utilizing that to establish appropriate recall regimen for those patients," Sanders says.

"Oral health is essential to whole-body health, and the people who help take care of it, hygienists, are prevention specialists. That is our role. All of our knowledge is based on understanding disease, how it happens, and how we can help prevent it," Clarke says. "When you have a healthy mouth, the rest of the body works well."

The pandemic also led to some changes for the worse. Gurenlian notices how many skilled dental hygienists have stepped away from the profession. However, she doesn't think it has to be permanent.

"Once we have a better control over this virus, get more people vaccinated, and reach herd immunity, that may change," Gurenlian says.

Moreover, the hygiene community found that adjusting to change can take time. Change is not unfamiliar in hygiene, however. Both Miller and Gurenlian remember when hygienists didn't wear gloves when treating patients before HIV, hepatitis, and the other blood-borne pathogen scares of the ‘80s and ‘90s. It took time to get used to wearing gloves, but once they did, hygienists realized that they could still do everything they did before wearing the gloves. Now, with PPE, it's the same thing, Gurenlian says, and she is confident that everyone will adjust.

"It's just the learning curve," Gurenlian says. "You adapt accordingly."

"We've mastered infection control and have for years," Miller says.

The pandemic also exposed a division within the hygiene community, Sanders says. Social media revealed that some hygienists think of themselves as teeth cleaners and nonessential workers who shouldn’t risk their lives to clean teeth. Others think of themselves as essential inflammatory specialists who can reduce the impact of this disease on their communities.

"Now dental hygiene is taking a big, deep breath from behind our N95s and trying to figure out how we move forward," Sanders says, adding that she believes the ADHA can put the community back together with strong leadership.

"When you go through a big shift like this, there's a spectrum,” Clarke says. “Some think aerosol management was never an issue before, and it's not an issue now. Then there's also the opposite end of the spectrum of hygienists who are still not comfortable using aerosols or even practicing. So, we're still in this transition, and it will be a while before everything settles."

Gurenlian thinks telehealth is a game-changer for hygiene. Telehealth allows hygienists access to individuals who do not have access to or are reluctant to receive oral health care. Hygienists can use telehealth to quickly respond to any dental emergency or condition to get these patient populations the care they need.

"It opens doors for greater opportunity in oral health care,” she says. “I love telehealth; there are wonderful opportunities associated with that for both dentistry and dental hygiene. I see it in medicine, dentistry, and dental hygiene as a technology that we need to tap into even more."

“Telehealth and hygiene are huge because of this,” Clarke says. “It is excellent for preventive care and education, and for hygienists that are completely solo practitioners that have their own business, whether they're independent practice or expanded functions, depending upon which state they're in. When they have to collaborate with their patients and other health care providers, COVID really accelerated growth and acceptance of telehealth."

Another trend during COVID that impressed Gurenlian is the innovation in the industry. Many scientists are working to improve aerosol management in the operatory with technology to provide a safer environment to deliver care, she says.

"We have this horrible situation, that this virus is killing people, making them terribly, terribly ill. But on the other side, we have wonderful individuals who are good at solving problems and look at other alternatives that could help us," Gurenlian says. "Isn't that wonderful that people use their abilities in such a great way?"

Products are helping hygienists, too. Clarke likes the A-flexX Assist Arm. The line of products provides an extra hand to hygienists, who are solo practitioners in the operatory. The autoclavable funnel reduces ambient aerosols while hygienists deliver care. The devices attach to the chair and curve around the patient's head to hover above the patient's oral cavity.

"It was a company founded by a hygienist, designed by a hygienist who knows exactly what a hygienist needs. It's really cool," Clarke says.

One tool that Miller thinks has made a significant difference for hygienists during the pandemic is Florida Probe’s VoiceWorks system for periodontal charting. An additional person in the operatory using a pen or keyboard helped with charting in the past, but voice-activated charting allows the hygienist to remain autonomous in the operatory and reduce the risk of transmission of the virus by reducing headcount in the area, she says. VoiceWorks is compatible with most practice management software.

"And it speaks 13 languages. It's used all over the world," Miller says, who says she has worked with the product for many years.

The pandemic also highlighted how little research exists about the best steps for hygienists to reduce risks of virus transmission. At first, Sanders says most hygienists stopped using their ultrasonic instruments and went back to hand tools.

However, without HVE units in use, the microbial or virulence load of the aerosols generated with hand tools is unclear. Sanders thinks that in addition to using HVE units, hygienists should employ ways to reduce microbial counts in the oral cavity, whether with lasers, preprocedural mouth rinses, or other methods. While these don’t have research to support that they effectively reduce the virus transmission, Sanders feels that being overly cautious is not a bad thing in this area. 

"We were creating this layered approach to infection control. So maybe we are currently wearing a belt and suspenders at the same time, but the reality is we are in a global health crisis, and it's our responsibility first and foremost to protect the public," Sanders says.

As part of the new normal, Sanders thinks we will continue to see touchless systems in practice. No forms on clipboards filled out in the reception area, no postcard reminders in the mail.

"We optimized a lot of that through technology, sending our patients their virtual paperwork, really leaning on the internet and programs that we have available to communicate with our patients or streamline things within the front office," Sanders says.

In July, the Pew Research Center revealed that most people got their information from national and local news outlets (61%).¹ Sanders says that leaves dental professionals at the mercy of what the news outlet says, or doesn't say, about the safety of visiting a dental practice during a pandemic. Sanders would like to see the dental community take the lead in educating patients, even when they aren't sitting in the chair.

"We could use technology to reach our patients, educate them, send out newsletters electronically, and videos to our patients to educate them," Sanders explains. "We need to let them know about the things we are doing to protect staff and patients during this current health crisis."

The technology that facilitates these systems and processes has added efficiencies to the practice, she says, and patients appreciate it.

"It's been a change that's here to stay," Sanders says. "That's the culture shift that maybe we needed in dentistry for a long time."

How to Move Forward into the New Normal

"Many of us will admit that we were caught with our scrub pants around our ankles, so to speak," Sanders says. "We can learn from this.”

Acknowledging that this is a health crisis, Sanders says that many practices bought high-efficiency particulate air (HEPA) filtration and HVE systems, technology subscriptions, foggers, UVC germicidal lamps, and so on. Then there was all the PPE and the related expenses associated with that. It was an expensive mistake, she says, especially when patients weren't coming in.

"All of which we have known for a long time that we should have been using. So maybe if we would have done a lot of these things before this, the stress, strain, panic, and financial burden would have been more alleviated for many of us," Sanders says. "Now is our chance to learn from that mistake and move forward in a positive way."

Miller encourages hygienists to believe they are essential health care providers. Periodontal disease is a medical condition that affects patients from head to toe, she says, meaning it is not isolated to the mouth. Caring for patients with an active infection in their mouth is an essential medical procedure hygienists provide, she says.

"We're the ones that need to be speaking to our patients about reducing the inflammation they have in their mouth. The less inflammation patients have in their mouth, the easier it is to control inflammation in other areas of their body," Miller says.

Gurenlian agrees, adding that hygienists should take ownership and expand their role to elevate their clinical practice. She wants hygienists to take advantage of the heightened public awareness of hygienists' responsibilities as health care providers.

"We are prevention specialists and oral health care providers. We own a part of health care that is special and important, and we have to take responsibility for the work we do," Gurenlian says. "We should use science and evidence to make what we do even better."

Perhaps most importantly, Gurenlian says, hygienists cannot rest on their laurels. She encourages hygienists to leave nothing on the table and explore as many opportunities as possible of what is available to them because of the pandemic.

"I wouldn't be afraid of anything at this point," Gurenlian says.

Sanders thinks continuing education (CE) is essential, too.

"We need to think about continuing education, not simply as the checkbox that we need to check off to renew our license, but rather, we need to look to CE as our source for the information we need to remain current in our practices," Sanders says.

Clarke thinks making connections with patients through the PPE is vital. Moreover, patients might feel vulnerable because patients take their masks off while hygienists do not. While many people have become more comfortable with not seeing people's faces during interactions over the past year, she advises hygienists to work harder in other ways to connect with patients to make them comfortable.

"We have to use a lot more words, our eyes, and facial expressions in a different way to communicate," Clarke says, adding that she thinks face coverings are here to stay in the profession. "I wouldn't be surprised if it was where if you're not wearing a mask, you're wearing a face shield. And then, you put on a mask when you are getting ready to go into a patient's mouth. But we will always have some sort of face covering."

Clarke also recommends that when interviewing, dental hygienists should ask about infection control procedures at the practice.

"Most clinicians should be asking that question, especially if they are working in a clinical-type setting," Clarke says.

Dentistry is notorious for being resistant to change, Sanders says. However, dentistry changed dramatically from the beginning of 2020 to the end of it. She says dental professionals will emerge more resilient and able to improve patient care. This also can be an opportunity to come together with a united voice and collaborate. Sanders wants these core values to drive the profession to excellence.

"Now, more than ever, the work that we do has truly never been more impactful, and I believe we are better and stronger together," Sanders says. "Let's use what we've learned about this pandemic and each other to come together and better our communities."

Reference

1. Shearer E. Local news is playing an important role for Americans during COVID-19 outbreak. Pew Research Center. Published July 2, 2020. Accessed February 23, 2021. https://www.pewresearch.org/fact-tank/2020/07/02/local-news-is-playing-an-important-role-for-americans-during-covid-19-outbreak