Changes in Oral Health Policies and Guidelines During the COVID-19 Pandemic

Dental hygiene clinical faculty attitudes and likelihood of working during the COVID-19 pandemic

OBJECTIVE

To identify circumstances that influenced dental hygiene clinical faculty's likelihood of working during the COVID-19 pandemic, and to explore attitudes (responsibilities, personal issues, ethics, and policy statements) about working.

METHODS

This cross-sectional study used a purposive sample of dental hygienists (n = 1710) employed in academic clinical settings that held full-time, part-time, or adjunct appointments. The Health Care Workers' Attitudes to Working During a Pandemic survey was utilized. Likelihood scores were calculated based on respondents more or less likely to work under differing circumstances. Frequencies of agreement for attitudes were developed. Correlations were explored between likelihood scores and demographic data. Answers to the open-ended questions were categorized and described.

RESULTS

The response rate was 13.5% (225/1710). Only one-third of respondents had a likelihood score of 100%. Factors with the greatest impact on likelihood to work were personal protective equipment. Almost all respondents' attitudes of working indicated that their employer is responsible for providing PPE. Over 90% felt their main responsibility was to themselves/family. Correlation analyses resulted in no significant associations between likelihood scores and age, etc. Faculty are considering leaving their jobs because of pay cuts and/or not feeling safe.

CONCLUSION

Likelihood of working for dental hygiene faculty represents several personal and ethical decisions. Most respondents want employers to be responsible for their on-the-job safety. In addition, personal and work-related issues were causes of unease. The pandemic has had far-reaching implications on day-to-day work of dental hygiene clinical faculty as well as on the long-term trajectories and views on employment in higher education.

Investigating the perceptions and experiences of Canadian dentists on dental regulatory bodies' communications and guidelines during the COVID-19 pandemic

OBJECTIVE

Dental regulatory bodies aim to ensure the health and safety of dentists, dental staff patients and the public. An important responsibility during a pandemic is to communicate risk and guidelines for patient care. Limited data exist on the perceptions and experiences of dentists navigating new guidelines for mitigating risk in dental care during the pandemic. The objective of this study was to use a qualitative approach to explore how dentists in Canada experienced and perceived their regulatory bodies' communication about COVID-19 risks and guidelines during the pandemic.

METHODS

Participants were Canadian dentists (N = 644) recruited through the email roster of nine provincial dental associations or regulatory bodies. This qualitative analysis was nested within a prospective longitudinal cohort study in which data were collected using online questionnaires at regular intervals from August 2020 to November 2021. To address the objective reported in this paper, a conventional qualitative content analysis method was applied to responses to three open-ended questions included in the final questionnaire.

RESULTS

Participants encountered challenges and frustrations amid the COVID-19 pandemic, grappling with diverse regulations and communications from dental bodies. While some bodies offered helpful guidance, many participants felt the need for improved communication on guidelines. Dentists urged for expedited, clearer and more frequent updates, expressing difficulty in navigating overwhelming information. Negative views emerged on the vague and unclear communication of COVID-19 guidelines, contributing to confusion and frustration among participants.

CONCLUSION

As COVID-19 persists and in planning for future pandemics, these experiential findings will help guide regulatory bodies in providing clear, timely and practical guidelines to protect the health and safety of dentists, dental staff, patients and the public.

Personal protective equipment during COVID-19: A natural history of dental and dental hygiene regulatory guidance in Canada

BACKGROUND

Due to the evolving nature of COVID-19, there is evidence that COVID-19-specific infection prevention and control guideline (IPCG) documents formulated for oral health care settings are also changing rapidly. To better inform future policies, a comprehensive review of all IPCG documents across different phases of restrictions for oral health care practitioners is required.

TYPES OF STUDIES REVIEWED

A search was performed for documents shared from March 2020 through January 2022 on websites of oral health regulatory authorities in Canada's 10 provinces and 3 territories. The authors performed a narrative review of the identified IPCG documents for dentists (n = 78) and dental hygienists (n = 57).

RESULTS

Overall findings from more than 100 IPCG documents distributed during a period of 23 months revealed that the frequency of these updates differed among jurisdictions and between the 2 oral health care practitioners (ie, dentists and dental hygienists) within the same jurisdiction. The most notable observation was the different face-covering recommendations for dentists and dental hygienists within the same jurisdiction during the same timeframe. A common document was sometimes observed for dentists and dental hygienists, however, most jurisdictions had separate IPCG documents.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

The different approaches could have been justified on the basis of prevalence of COVID-19 and availability of personal protective equipment; however, there was a risk of creating confusion about IPCG best practices. The findings of this review will support decision makers when planning future development and dissemination of regulations for all oral health care practitioners.

Canadian dental hygienists' experiences and perceptions of regulatory guidelines during the COVID-19 pandemic: a qualitative descriptive analysis

BACKGROUND

In Spring of 2020, due to the COVID-19 pandemic, Canadian provincial dental hygiene regulatory bodies implemented new practice guidelines. Reports of stress, anxiety and conflict experienced by dental hygienists have been linked to miscommunication between oral health regulators at this time. Limited data exists on the perceptions and experiences of dental hygienists navigating new guidelines for dental hygiene care during the pandemic. Therefore, the objective of our study was to explore via descriptive thematic analysis how dental hygienists experienced and perceived: i) dental hygiene practice during the COVID-19 pandemic, and ii) their regulatory body's COVID-19 guidelines.

METHODS

Participants were identified through provincial dental hygiene licensing bodies. Online bi-monthly questionnaires were administered to participants (n = 876) from December 2021 to January 2022. Two open-ended questions were asked in the questionnaire. A qualitative descriptive thematic analysis was applied to these two questions.

RESULTS

Major themes at baseline relayed challenges related to workplace compliance, patient treatment and communication of practice protocols. Across responses, hygienists confirmed conflicting messaging from regulators and guideline interpretations as stressors impacting their professional practice and satisfaction within the profession. Participant responses at endpoint cited increased satisfaction with regulatory guidelines as the pandemic evolved, yet inconsistencies in regulators' messaging was noted as a prevailing issue.

CONCLUSION

Inconsistent guideline messaging reflects an increased need for collaboration amongst oral health care regulators to streamline protocols for practice and reduce interprofessional conflict in pandemic circumstances. A national unified approach is warranted in establishing guidelines for dental hygiene practice in Canada.

Electrolyzed water for the microbiologic control in the pandemic dental setting: a systematic review

BACKGROUND

Electrolyzed water has brought recent attention due to its antimicrobial properties. Indeed, electrolyzed water has been proposed to sterilize dental materials and instruments without compromising their structural integrity. In addition, electrolyzed water has been proposed as a mouthwash to control bacterial and viral oral infections without detrimental effects on the oral mucosa. However, no current consensus or evidence synthesis could indicate its potentially favorable use in the dental setting, particularly during the COVID-19 context. Therefore, this systematic review aimed to elucidate whether electrolyzed water could improve microbiologic control in the COVID-19 pandemic dental setting.

METHODS

MEDLINE via Pubmed, EMBASE, Cochrane's CENTRAL, Scopus, LILACS, and Web of Science databases were searched up to September 2021 to identify experimental studies utilizing electrolyzed water for eliminating microorganisms in a dental setting. Besides, a manual and a grey literature search were performed. The data selection and extraction were performed individually and in duplicate. The Risk of Bias (RoB) was assessed with the Nature Publication Quality Improvement Project (NPQIP) score sheet. The study protocol was registered at PROSPERO CRD42020206986.

RESULTS

From a total of 299 articles, 63 studies met the inclusion criteria. The included studies assessed several types of electrolyzed waters, which showed a high disinfection potential when used to deal with different oral conditions. Electrolyzed water demonstrated a broad antimicrobial spectrum and was highly efficient in the dental office disinfection against viruses, fungi, and bacteria, being compatible with most dental materials. In addition, electrolyzed water could protect against SARS-CoV-2 infection and contamination in the dental office. Regarding the RoB, only 35.18% of entries were answered as 'Yes', thus achieving less than half of the reporting sheet.

CONCLUSION

Electrolyzed water effectively disinfects contaminated surfaces, dental materials, and equipment. Therefore, their use is recommendable in the SARS-CoV-2 pandemic dental setting.

Utilization of rapid antigen tests for screening SARS-CoV-2 prior to dental treatment

Potential aerosols containing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral particles can be generated during dental treatment. Hence, patient triage is essential to prevent the spread of SARS-CoV-2 in dental clinical settings. The present study described the use of rapid antigen tests for SARS-CoV-2 screening prior to dental treatment in an academic dental clinical setting in Thailand during the pandemic. The opinions of dental personnel toward the use of rapid antigen test screening prior to dental treatment were also assessed. From August 25 to October 3, 2021, dental patients who were expected to receive aerosols generating dental procedures were requested to screen for SARS-CoV-2 using a rapid antigen test before their treatment. A total of 7,618 cases completed the screening process. The average was 212 cases per day. Only five patients (0.07%) were positive for SARS-CoV-2 in the rapid antigen screening tests. All positive cases exhibited mild symptoms. For the questionnaire study, experienced dental personnel frequently and consistently agreed with the use of the rapid antigen test for SARS-CoV-2 screening, which made them feel safer during their patient treatment. However, implementing rapid antigen tests for SARS-CoV-2 may increase the total time spent on a dental appointment. In conclusion, a rapid antigen test could detect the infected individual prior to dental treatment. However, the specificity of rapid antigen tests for SARS-CoV-2 must be taken into account for consideration as a screening process before dental treatment. The enhanced infection control protocols in dental treatment must be consistently implemented.

Assessing the Compliance of Dental Clinicians towards Regulatory Infection Control Guidelines Using a Newly Developed Survey Tool: A Pilot Cross-Sectional Study in India

Adherence to the dental practice regulatory guidelines instituted during the COVID-19 pandemic is essential to minimize the transmission of SARS-CoV-2 strains. Given the lack of a valid and reliable survey tool to assess the adherence to dental practice guidelines, this study aims to develop, validate, and test a survey tool on a pilot sample of dental clinicians practicing in India. A survey tool was developed/validated through a sequential phasic approach: Phase I- developing survey using conceptual and literature framework; Phase II: ascertaining its validity and reliability; Phase III: pilot testing; and Phase IV: assessing construct validity by exploratory factor analysis (EFA) on the responses collected in Spring 2021. The EFA was achieved using a traditional unweighted least squares extraction method through a varimax rotation with Kaiser normalization. A six-factor solution with 18 items (with the global reliability of 86%) related to screening, regular infection prevention measures, infection control inside the dental operatory, disinfection of the dental unit, disposal, and other COVID-19-specific preventive measures were extracted. Our sample had higher compliance with regard to providing alcohol-based hand scrubs, providing protective gear to attendees, collecting travel/medical history, and screening patients for COVID-19 symptoms. In contrast, less compliance was observed regarding the use of paperless forms of practice and rubber dams in the operatory. The use of a validated survey tool ensures the collection of reliable and valid data, which can serve as baseline data to measure the uptake and effectiveness of dental practice regulatory guidelines in a clinical setting and community dental health clinics.

Dental high-speed handpiece and ultrasonic scaler aerosol generation levels and the effect of suction and air supply

Objective:

Exposure to aerosol spray generated by high-speed handpieces (HSHs) and ultrasonic scalers poses a significant health risk to oral health practitioners from airborne pathogens. Aerosol generation varies with different HSH designs, but to date, no study has measured this.

Materials and methods:

We measured and compared aerosol generation by (1) dental HSHs with 3 different coolant port designs and (2) ultrasonic scalers with no suction, low-volume evacuation (LVE) or high-volume evacuation (HVE). Measurements used a particle counter placed near the operator’s face in a single-chair, mechanically ventilated dental surgery. Volume concentrations of aerosol, totaled across a 0.3–25-µm size range, were compared for each test condition.

Results:

HSH drilling and scaling produced significantly high aerosol levels (P < .001) with total volume concentrations 4.73×108µm3/m3 and 4.18×107µm3/m3, respectively. For scaling, mean volume of aerosol was highest with no suction followed by LVE and HVE (P < .001). We detected a negative correlation with both LVE and HVE, indicating that scaling with suction improved operator safety. For drilling, simulated cavity preparation with a 1-port HSH generated the most aerosol (P < .01), followed by a 4-port HSH. Independent of the number of cooling ports, lack of suction caused higher aerosol volume (1.98×107 µm3/m3) whereas HVE significantly reduced volume to −4.47×105 µm3/m3.

Conclusions:

High concentrations of dental aerosol found during HSH cavity preparation or ultrasonic scaling present a risk of infection, confirming the advice to use respiratory PPE. HVE and LVE both effectively reduced aerosol generation during scaling, whereas the new aerosol-reducing ‘no air’ function was highly effective and can be recommended for HSH drilling.

Oral Antiseptics against SARS-CoV-2: A Literature Review

Dentists are health care workers with the highest risk of exposure to COVID-19, because the oral cavity is considered to be a reservoir for SARS-CoV-2 transmission. The identification of SARS-CoV-2 in saliva, the generation of aerosols, and the proximity to patients during dental procedures are conditions that have led to these health care workers implementing additional disinfection strategies for their protection. Oral antiseptics are widely used chemical substances due to their ability to reduce the number of microorganisms. Although there is still no evidence that they can prevent the transmission of SARS-CoV-2, some preoperative oral antiseptics have been recommended as control measures, by different health institutions worldwide, to reduce the number of microorganisms in aerosols and droplets during dental procedures. Therefore, this review presents the current recommendations for the use of oral antiseptics against SARS-CoV-2 and analyzes the different oral antiseptic options used in dentistry.

Are aerosol control devices effective in preventing the spread of dental aerosol?

Background

In dental clinics, aerosols produced from dental instruments have become a matter of concern following breakout of coronavirus disease 19 (COVID-19) evolving into a pandemic. This study compared aerosol reduction systems and in terms of their ability to reduce Enterococcus faecalis (E. faecalis) contaminated aerosol in a simulated dental office set-up.

Methods

Closed clinic model with manikin and mandibular molar typodont was simulated. For 10 min, the air and water dispersed by the rotating bur mounted on an aerator was contaminated by pouring the suspension containing 1-3 × 10⁸ CFU/mL E. faecalis directly on the bur. During and after the procedures, the air within the cabin was also sampled. CFU count was recorded and scored. The mean CFU scores obtained from agar plate count and air sampling device was compared using Kruskal-Wallis H test among groups with 5% significance threshold.

Results

The use of WS Aerosol Defender device led to greater CFU scores on the agars levelled to patient's chest compared to other directions (p = 0.001). Combined use of VacStation and WS Aerosol Defender resulted in significantly decreased CFU score in the air samples compared to experimental and positive control groups (p = 0 < 0.05).

Conclusions

Although the devices prevented the spread of aerosol around the patient to some extent, they could not completely eliminate the contaminated aerosol load in the cabin environment.

COVID-19 Effects on Income and Dental Visits: A Cross-sectional Study

OBJECTIVES

In April 2020, the Japanese government declared a state of emergency owing to the outbreak of the novel coronavirus disease (COVID-19) pandemic, which resulted in reduced workforce and job losses. Furthermore, income is one of the most consistent predictors of dental visits. Therefore, this study examined the association between income changes and dental clinic visits during the COVID-19 state of emergency in Japan.

METHODS

An online, self-reported cross-sectional survey about health activities including dental visits during the first COVID-19 state of emergency was conducted in Osaka, Japan (June 23 to July 12, 2020). Among participants with toothaches, the assessment for the association between "refrained from visiting a dentist despite wanting treatment for toothache during the state of emergency (refrained treatment)" and income changes before and after the state of emergency using a multivariate Poisson regression model adjusted for sex, age, self-rated health, frequency of regular dental visits, and employment status.

RESULTS

Among 27,575 participants, 3,895 (14.1%) had toothaches, and 1,906 (6.9%) reported refrained treatment. Among people with decreased income (n = 8,152, 29.6% of overall participants), the proportions of the refrained treatment group were 8.0% (income decreased by 1%-49%), 9.9% (50%-99% decreased), and 9.1% (100% decreased). Among participants with toothache, after adjusting for all variables, compared with participants with no income change, we observed significantly higher prevalence ratios (PRs) for refrained treatment in those who experienced a decreased income owing to COVID-19 (1%-49% decrease: PR = 1.08; 95% confidence interval [CI], 1.005-1.17; 50%-99% decrease: PR = 1.18; 95% CI, 1.06-1.32; 100% decrease: PR = 1.18; 95% CI, 1.04-1.33).

CONCLUSION

Decreased income was associated with refrained dental treatment during the COVID-19 state of emergency in Osaka, Japan. The economic damage related to the COVID-19 pandemic could lead to oral health inequalities.

KNOWLEDGE TRANSFER STATEMENT

Our study found that individuals with decreased income owing to COVID-19 before and after the state of emergency showed significantly higher prevalence ratios for refraining from visiting a dentist despite wanting treatment for toothache. We believe that our study makes a significant contribution because it provides novel, basic data that economic damages related to the COVID-19 pandemic might expand to oral health inequalities.

The triangle of inequality in dental services: arguments for a new conceptual framework

This short communication paper aimed to compile the main determinants of inequality in dental services by distinguishing between access, utilisation, and provision of dental services. Recent findings integrated, and a dedicated conceptual framework entitled “Triangle of inequality in dental services” has been suggested. These can contribute a rich knowledge in this area and open a new window for policymakers and researchers to seek applied interventions to decrease inequality and improve access and utilisation in communities. This paper aims to synthesise the available evidence and add value to the scope. It highlights a dedicated concept for inequality in dental services beyond other areas of public health.

Adherence to COVID-19 Preventive Measures among Dental Care Workers in Vietnam: An Online Cross-Sectional Survey

An online cross-sectional survey using a "snowball" sampling method was carried out to assess the adherence to COVID-19 preventive measures among dental care workers (DCWs) during the pandemic. Six questions concerning the COVID-19 preventive guidelines issued by the Vietnam Ministry of Health were used to evaluate DCWs' adherence to preventive measures at dental care clinics. The quality of life of DCWs was assessed using the WHO-5 questionnaire and was defined as low if the total score was less than 13 points. Factors relating to adherence to COVID-19 prevention measures of DCWs were determined by multivariate linear regression analysis. In total, 514 DCWs completed the questionnaire. A total of 37% DCWs rated their quality of life as low. Regression analysis suggested that older age, a better quality of life, living in an urban area, and training on COVID-19 prevention were associated with better adherence to COVID-19 preventive measures, while being a dentist and lack of personal protective equipment was associated with less adherence to COVID-19 preventive measures. The pandemic had a significant negative impact on the physical and mental health of DCWs. Therefore, specific national guidelines for the prevention and control of the spread of COVID-19 in dental facilities should be issued.

Psychological Distress among Bangladeshi Dental Students during the COVID-19 Pandemic

Background: Psychological sufferings are observed among dental students during their academic years, which had been intensified during the COVID-19 pandemic. Objectives: This study assessed the levels and identified factors associated with psychological distress, fear and coping experienced by dental undergraduate students in Bangladesh. Methods: A cross sectional online survey was conducted during October-November, 2021. The Kessler Psychological Distress Scale (K-10), Fear of COVID-19 Scale (FCV-19S) and Brief Resilient Coping Scale (BRCS) were used in order to assess psychological distress, fear and coping strategies, respectively. Results: A total of 327 students participated; the majority (72%) were 19-23 years old and females (75%). One in five participants were infected with COVID-19 and 15% reported contact with COVID-19 cases. Negative financial impact (AOR 3.72, 95% CIs 1.28-10.8), recent or past COVID-19 infection, and contact with COVID-19 cases were associated with higher levels of psychological distress; but being a third year student (0.14, 0.04-0.55) and being satisfied about current social life (0.11, 0.03-0.33) were associated with lower levels of psychological distress. Being a third year (0.17, 0.08-0.39) and a fourth year student (0.29, 0.12-0.71) were associated with lower levels of fear. Health care service use and feeling positive about life were associated with medium to high resilience coping. Conclusions: This study identified dental students in Bangladesh who were at higher risk of psychological distress, fear and coping during the ongoing pandemic. Development of a mental health support system within dental institutions should be considered in addition to the academic and clinical teaching.

Knowledge, Perceived Risk, and Preventive Behaviors amidst Covid-19 Pandemic among Dental Students in Malaysia

PURPOSE

Coronavirus disease 19 (COVID-19) has affected dental education in Malaysia. However, studies on dental students' knowledge, perception, and behaviors with regards to COVID-19 are very limited. Thus, this study aims to determine the knowledge status, perceived risk, and preventive behaviors of dental students in Malaysia regarding COVID-19.

METHODS

A cross-sectional study was conducted among students from 13 dental schools across Malaysia using online questionnaires.

RESULTS

From 355 respondents, 93.5% obtained a high score of knowledge of COVID-19. Female respondents scored higher than males in perceived risks and preventive behaviors. Chinese respondents scored highest in knowledge, while Malay respondents had the highest perceived risk score. The mean preventive behavior score did not vary across ethnicity. On-campus students scored higher in knowledge and perceived risk whereas off-campus students practiced more preventive behaviors. Clinical students' knowledge score was higher than preclinical students. Final year students scored higher in knowledge and perceived risk compared to their juniors.

CONCLUSION

The majority of dental students have good knowledge and a high perceived risk of COVID-19, and they practiced most of the preventive behaviors. However, the latest information on this disease should be incorporated into dental schools' curriculums and updated periodically.

Procedures Used in Managing SARS-CoV-2 Infected Dental Personnel or Patients: A Case Study From a Thai Dental Hospital

SARS-CoV-2 can transmit undetected from asymptomatic and pre-symptomatic patients in dental clinics. Triaging dental patients using temperature and questionnaire screening cannot completely exclude asymptomatic SARS-CoV-2 infected individuals. Hence, asymptomatic SARS-CoV-2 infected individuals might visit dental hospitals/clinics seeking dental treatment without knowing that they are infected and might infect others, especially in a pandemic area. Ideally, a nasopharyngeal swab for real-time polymerase chain reaction or rapid antigen screening for dental personnel and patients prior to their appointment should be done. However, the implementation of this approach is impractical in some situations. Here, we describe the procedures for dental hospitals/clinics in case of an asymptomatic SARS-CoV-2 infected individual involved in dental service/treatment and later after testing positive for SARS-CoV-2. Potential closely contacted individuals were traced and classified according to their exposure risk. The recommended course of action is to identify individuals based on their risk and take the risk-appropriate action. We also discuss the implementation of these procedures in a dental setting during the COVID-19 pandemic in our school as a case study.

Recommendations for Safe Dental Care: A Systematic Review of Clinical Practice Guidelines in the First Year of the COVID-19 Pandemic

In the context of a pandemic, the rapid development of clinical practice guidelines (CPGs) is critical to guide dental staff towards the safe provision of dental care; detailed knowledge of the recommendations will help to achieve the intended results. We carried out a systematic review of the recommendations in clinical practice guidelines (CPGs) on the provision of dental care issued during the first year of the COVID-19 pandemic. A systematic database search was performed in MEDLINE, EMBASE, LILACS, Epistemonikos, and Trip databases to identify documents with recommendations intended to minimize the risk of COVID-19 transmission during dental care. The selection process and data extraction were carried out by two researchers independently. The majority of CPGs recommended the use of rubber dam, high-volume evacuator, mouthwash prior to dental care, four-handed work, and mechanical barriers. The use of aerosol-generating equipment should be avoided whenever possible. In aerosol-generating procedures, the use of a N95 respirator (or similar) is recommended, in addition to a face protector, an impermeable disposable apron/gown, a cap, and gloves. The CPGs developed during the first year of the pandemic offer recommendations which guide dental staff in providing safe dental care, minimizing exposure to SARS-CoV-2 and reducing the risk of COVID-19 infection in the clinical environment. Such recommendations must, however, be updated as new evidence arises.