In preparing to write this editorial about the impact of the COVID-19 pandemic on dentistry, around mid-April while home quarantined, I sought out my Magic 8 Ball for its predictive wisdom. Unfortunately, each query produced the same response, “Ask again later.” At this time, the nation appears to be approaching the apex of the (initial?) peak of the viral curve, so read this editorial from that perspective. It will be interesting to see how this relates when published this summer.
Where to begin? Should we start in China with the slow trickle of reports about a novel virus that grew ever steadily into a world-engulfing torrent? Perhaps the ill-fated Diamond Princess cruise ship? For many in the United States outside the Pacific Northwest, the COVID-19 pandemic seemingly kicked off when National Basketball Association (NBA) player Rudy Gobert, center for the Utah Jazz, tested positive for SARS-CoV-2. Shortly after this news, several major dominos were quick to fall, resulting in cancellations of the NBA and National Hockey League seasons, in addition to the National Collegiate Athletic Association March Madness tournament, ultimately coalescing into a life devoid of any sense of normalcy.
Perhaps identifying a worthwhile starting point is folly, as not knowing exactly where to begin is not what makes this hard; it is not knowing how this will all play out. The pathway for exiting this pandemic that lies before society and our profession is unknown, which is worrisome. But, as the Beatles sang in “Ob-La-Di, Ob-La-Da,” “life goes on, bra.” This pandemic will inevitably subside and our lives, both professional and personal, will continue. The question is: what will be the lasting impact of SARS-CoV-2?
By most accounts, dentistry last faced a new adversary of this caliber in the early '80s when HIV exploded onto the scene, ushering in a new “normal” from which followed the establishment of universal precautions in dentistry. Although treating dental patients without the use of gloves seems ludicrous today, many surely remember when that wasn't the case. Dentistry has evolved with the times, albeit slowly on occasion, and it seems reasonable fallout from this pandemic will produce yet another new “normal.” Some are predicting wholesale changes to the practice of dentistry, particularly due to the risks inherent with airborne viruses like SARS-CoV-2 and aerosol-generating procedures (AGPs). The use of additional protective measures (N95 masks, powered air-purifying respirators, face shields, etc) as the new standard is not only logical but also quite likely, at least for the foreseeable future. However, questions about the anticipated availability of required personal protective equipment (PPE) and the particulars for safely treating assumed asymptomatic carriers are already surfacing as many are anxious to resume some semblance of normal clinical activities. Point-of-care testing is likely to be a cornerstone of returning to “business as usual,” although to be of maximum preventive use such testing must be widely available, have adequate sensitivity and specificity, and be capable of identifying clinically asymptomatic infected individuals early. In the end, much will likely be determined by this virus's natural course. Will it persist in seasonal recurrences like influenza or fade from prominence like the SARS and MERS coronaviruses? My guess is that the near future holds recurrent waves of infection (similar to the 1918 Spanish flu) directly tied to early efforts to reopen society, but that herd immunity coupled with a possible vaccine will prevail by 2021. Although quarantine and social distancing efforts here in the United States have been at least partially successful, unfortunately I have serious doubts regarding society's ability to tolerate the prolonged continuation or repetition of these strict viral mitigation efforts.
For health care providers to further reduce the risk of viral infection to near nil, which may be the expectation of some, many additional steps must also be taken. Currently concerns abound regarding the time the COVID-19 virus remains viable on clinical surfaces and in the air, prompting the recommendation of a three-hour waiting period between patients to allow time for aerosol deposition, coupled with extensive disinfection of the dental treatment environment. Employing a rotation of separate, isolated (ie, closed-off) clinical spaces can improve efficiency and access to care while minimizing risk of exposure and aerosolized viral spread. This type of solution may be viable in the short term, provided access to multiple rooms with isolation capabilities even exists. However, dental practices often have limited options regarding enclosed treatment rooms because of the popularity of open-space concepts, which are not conducive to minimizing viral spread from AGPs. Furthermore, negative-pressure rooms have also been suggested as a means of mitigation, but this level of infrastructure is virtually unheard of outside a hospital and incorporating such a system is likely cost prohibitive. Many of the mitigation measures incorporated into interim guidelines for treating confirmed or suspected COVID-19 patients are unlikely to be economically feasible long-term options for most of dentistry. How our profession and society reconcile with that fact will be quite telling, especially as it appears this pandemic will linger beyond the next few months. Time will tell if the risks currently associated with SARS-CoV-2 infection become generally accepted as part of life, as seems to be the case with influenza.
Briefly shifting focus away from the direct impact on clinical dentistry, the COVID-19 pandemic has profoundly altered all facets of dental education, impacting predoctoral students and residents alike. Didactic courses have been forced to move online, and traditional preclinical labs and clinic work have essentially ground to a halt. Dental schools are being tasked with finding creative and effective solutions to the educational challenges created by this virus. However, SARS-CoV-2 may ultimately serve as a surprising opportunity to alter dental education in a beneficial manner. Most dental schools in the United States traditionally require students to complete an arbitrary number of clinical procedures in addition to a host of competency exams. However, there is seldom any difference between a student just entering the clinics and one cleared for graduation in terms of their expected responsibilities and faculty oversight. Limitations of this traditional approach become readily apparent when contrasted against educational systems utilizing graduated responsibilities and entrustable with professional activities. In short, rather than strictly counting numbers, students could be treated similarly to residents, especially in their fourth year, allowing them to advance at a quicker pace as appropriate and become better prepared for practice beyond school. This pandemic may pave the way for real progress in dental education by forcing dental schools into adopting a truly effective competency-based system.
Ramifications stemming from SARS-CoV-2 on dentistry and society are far from over, and echoes from this pandemic are likely to reverberate for quite some time. However, as we approach the (hopefully) midway point in this crisis, there have been a multitude of noteworthy bright spots for our profession. Several dental providers have served on the front lines helping care for COVID-19 patients in hospitals and ICUs. Detailed interim treatment guidelines, rapidly compiled by several individual medical and dental professional societies, have been made public in efforts to maximize patient and provider safety by sharing critical information beyond their respective memberships. Across the nation, dental providers quickly heeded the call to halt elective procedures, effectively closing their practices to help “flatten the curve.” In many cases, much-needed PPE was donated or sold at cost by dental offices to nearby hospitals in preparation for the influx of COVID-19 patients. Despite the required closure of their practices, dentists, oral surgeons, and dentist anesthesiologists have continued to respond to patients with dental urgencies and emergencies and provide care as appropriate, all while potentially risking exposure to themselves, their staff, and their families. Although in some respects our challenges are just beginning to surface, dentistry should stand proud knowing it is successfully doing its part in facing this pandemic head-on.