The COVID-19 coronavirus has turned routine dental procedures into risky affairs that may expose clinician and patient alike to potentially deadly infection. While personal protective equipment (PPE) guidelines have ramped up for urgent and emergency care, infection control practices won’t be the same once the crisis is over. Edward F. Farkas, DDS, MA, vice dean of the Touro College of Dental Medicine, shared his thoughts about today’s best practices and what lies ahead for clinical care after the pandemic.
Q: How has the virus impacted standard practices for infection control?
A: The answer to the question of how COVID-19 will impact standard infection control practices is unknown, but change will be coming. Prior to COVID-19’s arrival on the scene, the diseases we were most concerned about in dentistry were those caused by bloodborne pathogens (BBP) such as hepatitis B, hepatitis C, and HIV.
Our dental operatory infection control strategies were geared to prevent these BBP from moving from patient to doctor, doctor to patient, and patient to patient. For the most part, these strategies were effective, easy to implement, and cost effective.
COVID-19 has disrupted that. Much of the COVID-19 playbook remains unwritten, though its primary mode of transmission seems to be airborne or picked up with hand contact. We therefore are left with the problem of redesigning our protective strategy to include defending against these airborne micron-sized viruses
Q: Specifically, how has the role of PPE changed?
A: Initially, gloves and masks were introduced into surgical theaters to protect the patient from receiving microbes carried by the doctor. With the introduction of universal precautions and the BBP standard, the tide shifted toward the protection of the healthcare provider.
With a virus like COVID-19, which can be transported on an aerosolized water droplet, that standard seems to need refinement, and upgrading, to filter out smaller and smaller particles. The PPE of the near future will have to protect our dentists and assistants from a virus that may have slipped through the PPE used previously. N95 masks and some sort of strategy to reduce the production of aerosol spray during handpiece use will be part of that.
Q: Have these changes affected how urgent and emergency care is being defined?
A: Urgent and emergency care are currently being treated differently in patients who are asymptotic and without reason to believe that they may be positive for COVID-19 and those patients who may have active COVID-19 infections.
Patients who may be positive for COVID-19 are being referred for treatment to facilities that have negative-pressure operatories and the highest-level PPE available. Under the previous BBP standard, that patient was treated in a standard dental operatory, with the healthcare provider using a higher level of PPE. Additionally, if possible, treatment is being delayed until the patient is no longer positive for coronavirus.
Q: Have these changes had any impact on follow-up care?
A: The PPE and infection controls changes that dentists will implement in response to the coronavirus pandemic will not influence the need for follow-up dental care in the United States. What will change in the delivery of follow-up care is that there is becoming a realization in the profession that with a little planning, most post-op care can be delivered more efficiently through a virtual or remote consultation.
For example, a post-op check of an extraction can be done with a patient FaceTiming with their practitioner. Clear aligner checks can be done in a similar manner, saving time and travel. Additionally, insurance companies are starting to reimburse for these visits, which will increase their utility and make them equal to an in-office visit financially.
Q: What role is technology such as teledentistry playing in non-urgent and non-emergency care?
A: Teledentistry allows us to evaluate and treat non-emergency situations without a visit to the dental office. It also helps the practitioner in sorting out those cases that really require a visit to the office. In the time of the COVID-19 pandemic, it is an especially important tool in keeping patients safe while meeting their dental needs.
Q: How do you think these changes will impact dentistry once the pandemic is over?
A: Teledentistry upgraded PPE. Air exchange systems will all outlive the pandemic. While the pandemic will recede, it is unlikely that the virus will disappear completely, unless we have a vaccine. The utility and safety upgrade that comes with their use is undeniable. Additionally, it can be assumed that teledentistry-specific instruments and tools will come to market that will greatly increase dental conditions that can be evaluated and treated.
Q: Are there any issues that you think are being overlooked as dentistry is focused on the pandemic?
A: I don’t think that there are issues that are being overlooked. I do think that many issues that we will need to resolve in order to treat our patients are in a state of flux. The ground beneath dentistry is shifting, and we must keep our balance utilizing data and science to lead the way.
Q: Do you have anything else you would like to add about care today and in the future?
A: Dentistry, post-pandemic, is entering a brave new world. We must analyze all threats to ourselves, our staff, and our patients and respond appropriately, putting into place measures that protect everyone while being cost-effective and allowing efficient treatment. I am sure that as a profession we will rise to the occasion and respond with practical and efficient solutions to the problem. We have done this before, and we will do this again.
Dr. Farkas is the vice dean and a professor of dental medicine at the Touro College of Dental Medicine. He was instrumental in the creation and development of the TCDM program, its initial accreditation by the Commission on Dental Accreditation, and the college’s clinical training facility. He holds a DDS from the New York University College of Dentistry and a master’s degree in dental education from the University of the Pacific/Bernerd School of Education. He maintains a private practice in Brooklyn, New York, as well.