Oral hygiene and its association with covid

A higher risk of oral diseases, inequities in oral health, and limited access to oral health care are also present in the populations that are disproportionately affected by the coronavirus disease of 2019 (COVID-19). Dental offices that did not provide emergency or urgent care were forced to close or have their hours drastically shortened as a result of COVID-19, which restricted routine and preventive care. Procedures used in dental treatment that produce aerosols can speed up the spread of viruses. The pandemic presents a chance for the dentistry profession to move away from surgical procedures and more toward non-aerosolizing, prevention-focused methods of care. If maintained into the future, regulatory reforms made to access oral health care during the pandemic may have a positive effect.

Introduction

On March 11, 2020, the World Health Organization labelled the global spread of the 2019 coronavirus illness (COVID-19) as a pandemic. SARS-CoV-2 is a brand-new virus for which there is neither a vaccine nor a cure, and no one in the general public is currently immune. The virus is mainly spread through direct or indirect human contact with droplets of an infected person’s respiratory fluid in the air.

The American Dental Association (ADA), the biggest dental organisation in the country, suggested on March 16, 2020, that dental offices delay elective dental procedures until April 6, 2020, and solely offer emergency dental care to lessen the load on hospital emergency rooms. Updated on April 1, 2020, the ADA urged offices to remain closed to all but urgent and emergency procedures until April 30 at the earliest due to the spike in illnesses. This significantly reduced people’s ability to receive dental care. In the week of March 23rd, 2020, the ADA Health Policy Institute found that 76% of dental offices were closed but only seeing emergency patients, 19% were fully closed, and 5% were open but seeing fewer patients.

Point-of-care testing at dental offices wasn’t available, and COVID-19 testing was not widely used. State and local government policies regarding the requirements for reopening various types of services, including dental services, vary, leading to a change in ADA guidance in mid-April 2020. This was due to the inability to test every patient and the possibility that symptomless or presymptomatic patients could be contagious. There are still unanswered questions regarding when individuals will prioritise and begin routine dental treatment in the midst of other postponed medical procedures. Utilization of dental services will be significantly impacted by the pandemic’s financial pressure and loss of dental insurance, the exact effect of which is still unknown.

In this commentary, we address the challenges in achieving dental care as a public health priority and explain why oral health care should be a priority in the fight against the pandemic. We’ll also point out areas for development, like ways to boost access to less-expensive, more equitable care for vulnerable groups and a greater emphasis on preventative care and non-aerosolizing dental procedures.

Importance of Oral Health

It was made explicit in the first and only Surgeon General’s Report on Oral Health published in 2000 (the second is now being written). The mouth is necessary for eating, speaking, smiling, and maintaining a high standard of living. Dental caries and periodontal disorders are the two most common oral ailments, and they are mostly avoidable. The most prevalent chronic childhood illness, dental caries, persists throughout adulthood. National data from 2011 to 2014 show that 32.7% of US people have untreated dental caries. Additionally, weighted averages from 2009 to 2014 revealed that 42% of people ages 30 and older had periodontitis. Depending on race and ethnicity, oral illness is more or less prevalent in the community. Infection, discomfort, and sepsis can all be brought on by the growth of oral illness, and the condition is expensive to cure. With proper oral hygiene, fluoride exposure, dental sealants, dietary adjustments, and other treatments, the development can be stopped or reversed in the early stages, in addition to primary prevention.

Populations with Oral Health and Chronic Disease Disparities: COVID-19 Puts Both at Increased Risk

Populations that are more susceptible to oral disorders are similar to those that are more susceptible to various chronic diseases. Stress, a poor diet, alcohol and cigarette use, substance abuse, behavioural health difficulties, domestic violence, and poverty are typical risk factors. The epidemic has intensified several of these factors. Both the aggravation of chronic diseases and poor oral health outcomes are caused by these and other socioeconomic determinants of health.

Oral illness and its related systemic health issues are more common among those susceptible to COVID-19, such as those from low socioeconomic backgrounds, minorities, elderly adults, persons with low levels of education, residents of rural areas, and those without insurance. During the COVID-19 pandemic, minority populations are more at risk. According to the Centers for Disease Control and Prevention (CDC), non-Hispanic blacks, Hispanics, American Indians, and Alaska Natives generally have the worst oral health of any racial and ethnic groups in the United States. These populations also have disproportionately higher incidences of COVID-19-related infection and death.

Diabetes and cardiovascular disease are two of the most common underlying comorbidities among COVID-19 hospitalised patients, according to the CDC. Although determining causality is difficult due to confounding data, and few randomised trials or longitudinal studies on the effects of treatment have been conducted, periodontal disease is linked to diabetes and cardiovascular disease. 

The COVID-19 pandemic has concerning ramifications for both individual and societal health as well as emotional and social functioning, according to researchers, who also note that “health care professionals have an important role in monitoring psychosocial needs and providing psychosocial support to their patients.” According to research, there is a significant connection between mental health issues like stress, anxiety, sadness, and loneliness and illnesses like periodontal disease, caries, and erosion of the teeth. Downstream, COVID-19 and oral health may also be related in other ways. Growing integrated practises and referrals between dental practitioners and behavioural health providers will be wise given the COVID-19 pandemic’s effects on mental health, increases in oral health risk factors brought on by the pandemic, and expected declines in per capita dental visits. To boost access to oral health treatments for disadvantaged populations, more work should be done to incorporate dental programmes that focus on prevention, screening, and risk assessment more effectively into primary care, obstetrics and gynaecology, and paediatric offices.

COVID-19 and Oral Health Disparities in Access to Care

In particular, populations with a high COVID-19 risk have inadequate access to dental treatment. “Avoid nonemergent dental care,” patients with COVID-19 signs are advised. Dental care should, if at all feasible, be postponed until a patient has healed, according to providers.

Areas where there is a shortage of dental health professionals are home to more than 49 million people in the US, according to the Health Resources and Services Administration. The COVID-19 epidemic has made this deficit worse by causing a reduction in preventative dentistry care for the sake of public health and safety. Additionally, there has been a large decrease in visits for health issues unrelated to COVID-19 at emergency rooms, a less-than-ideal but typical treatment location for those with oral health care access discrepancies. Similar to this, school-based oral health initiatives have been put on hold as a result of government-mandated school closings, including successful dental sealant programmes to prevent dental cavities, which are many children’s sole access to preventative oral health treatment in underprivileged populations. In the country, children from lower-income families, who are also more likely to suffer from caries, are less likely than those from higher-income families to have their teeth sealed, with respective rates of 39% and 46%.

Access gaps are particularly severe for minority and low-income groups. Poor and minority children are significantly less likely to have access to oral health care than their classmates who are not poor and who are not minorities, according to researchers. Additionally, dental insurance is more likely to be absent in these groups. One-third of the US population is anticipated to be covered by the oral health care safety net by 2020, particularly those who are low-income, uninsured, immigrants, members of racial and ethnic minorities, living in rural areas, and other underserved populations. Reduced access to this essential coverage has affected many of these communities, which frequently rely on Medicaid dental benefits, and has even resulted in their elimination. According to 2020 research, “several states have cut or terminated Medicaid dental coverage over the previous decade in response to fiscal constraints, with a parallel 10% decline in oral health care utilisation among low-income individuals.” The same report states there is frequently “difficulty obtaining Medicaid-contracted dental providers because just 20% of dentists nationwide take Medicaid” among individuals in at-risk populations who do have dental care under Medicaid. We may reasonably expect that these patterns will get worse if the COVID-19 pandemic consumes a significant percentage of state budgets.

COVID-19 and Dental Care: Aerosol-Generating Procedures Create Risk

Since the 1980s HIV epidemic, dental professionals have enhanced their infection control procedures and adopted general safety precautions. However, according to The New York Times, oral health workers are among the professions with the highest risk of COVID-19. Due to their proximity to patients who are infected, dental care professionals confront difficulties. During treatment, these patients’ mouths are open and uncovered, dramatically raising the risk of direct and indirect contact with infectious materials. Aerosol-generating treatments performed on known or suspected COVID-19 patients are classified by the Occupational Safety and Health Administration as “extremely high risk.” PPE shortages and the usage of tools and equipment that produce aerosols containing oral and respiratory fluids only increase the risk. The high-speed hand piece with its water spray cooling and the ultrasonic scalar used by hygienists to remove hard deposits on teeth are two devices that have been considered substantial breakthroughs in dental treatment and are responsible for two of the highest aerosol-creating processes.

Going Forward: Opportunities

Focus on prevention and promote nonaerosol-generating dental procedures

The foundation of public health is prevention. The COVID-19 epidemic offers the dentistry profession a chance to switch from an emphasis on surgical intervention to one on prevention. To succeed, we must embrace nonsurgical, non-aerosolizing caries prevention and management. Dental hygienists are recognised as authorities in prevention, and the profession has traditionally promoted municipal water fluoridation. The dental compensation paradigm, however, is focused on offering pricey, restorative operations that are out of many people’s financial grasp.

There are now guidelines that place a greater emphasis on prevention than is already the case with dental care (36–40). A nutritious diet with few added sugars is encouraged, community water fluoridation is implemented, topical fluorides are used, and dental health promotion in public places is some of the strategies. Medical facilities like primary care and pediatric offices should incorporate these oral health messaging and actions. Many options are available for both prevention and nonsurgical caries management. Dental resin sealants, glass ionomers used as sealants or in non-invasive, hand-operated restorative procedures, silver diamine fluoride, sodium fluoride varnish, and other topical fluorides that can be applied by the patient or by a professional are examples of materials that have been proven to work (40–42). The risk of viral transmission is lower since these materials can be administered without producing aerosols. These techniques offer a significant opportunity to increase vulnerable populations’ access to preventive and restorative care, especially when combined with policy changes that broaden the scope of practice for hygienists, sustainable payment reform, and changes in the education of oral health professionals. Together, providers and payers have a duty to move toward preventative care, especially in light of COVID-19’s potential to widen access gaps to oral healthcare for the most at-risk groups in the US. Prior to the pandemic, Birch et al. stated that an assessment of payer and provider practices demonstrated the need for “additional work on both the payer and provider sides to ensure that evidence-based prevention was both implemented appropriately and compensated sufficiently.”

Prevention and maintaining good oral health and sound tooth structure will shift reimbursement away from the existing expensive paradigm of reimbursement for restoration of tooth structure and function as healthcare remuneration shifts toward value-based treatment and a focus on health outcomes. Payment rules, in particular, which have historically supported surgical, high-end restorative procedures like crowns and multisurface fillings, must be revised to promote preventative and nonsurgical, non-aerosolizing therapies and make them more financially viable. To give priority to preventive and nonsurgical, non-aerosolizing therapies and make them more financially viable, reimbursement policies in particular, which have historically encouraged surgical, high-end restorative procedures like crowns and multisurface fillings, need to be reviewed.

Improve communication

It’s crucial to communicate about patient and provider safety. To determine whether COVID-19 transmission happens at the dental office, surveillance and monitoring are required. The risk of SARS-CoV-2 transmission during dental work cannot yet be estimated, according to the CDC. It is important to keep an eye on the availability of PPE for dental treatment and to assess the efficacy of different PPE options. Many professionals in the field of oral health are anxious to get back to work, and many clients can be wary of going into a dental clinic. Clarity and communication are essential, particularly with groups with low literacy rates. The value of maintaining good dental health and its connection to general wellness should be emphasised in messaging.

Protect and enhance Medicaid reimbursement

Medicaid programmes must provide children with dental care, but their approaches to providing oral health treatments to adults vary greatly, especially in terms of how thorough these services must be. “Extensive” Medicaid dental benefits for adults are only available in 19 states. Only 7.4% of US citizens aged 19 to 64 have access to Medicaid dental benefits; unfortunately, 33.6% do not. Serving at-risk groups both during and after the pandemic will therefore depend on the financial stability of dental safety-net clinics. These facilities will become even more essential as the need for more extensive and urgent care grows as a result of postponed and delayed treatment.

Medicaid enrollment rises during economic downturns, which has been well-documented. We may safely expect the same impact from this pandemic given the exceptional rate at which unemployment is rising. Dental Medicaid coverage is frequently under danger when states experience budget cuts. During the state fiscal years 2010 through 2012, 19 states reported limitations on Medicaid adult dental benefits in the immediate aftermath of the Great Recession. In response to the epidemic, many governments changed their public payment procedures to better serve their most vulnerable citizens. It will be crucial that lobbying activities maintain these temporary adjustments. However, given the current situation, policymakers must think about increasing adult dental benefits under Medicaid rather than cutting them. If Medicaid dental coverage are not expanded, access gaps will probably get worse.

Ease dental workforce restrictions

Regulations for dental practice during COVID-19 differ from state to state, and guidance is always evolving. It is essential that workforce regulations and licensure scope be reviewed as dental care resumes in order to address workforce utilisation bottlenecks and better meet the needs of communities. As of 2019, 11 states did not permit a dental team member to directly obtain preventative oral health services while not under the dentist’s direct supervision. In these states, a dentist must conduct an examination prior to a hygienist providing preventative care. Access to care would improve if practise constraints and workforce limitations were relaxed.

Advance teledentistry to address access gaps

Alternative delivery systems, such as teledentistry, have risen to the top of policy considerations as a result of the COVID-19 epidemic. Teledentistry facilitates the provision of oral health services via electronic communication channels, enabling providers and patients to interact without the typical time and space restrictions. Teledentistry’s special capacity to link underserved groups, principally rural ones, and the homebound with dental practitioners makes this approach especially well-suited to solve access issues during and after the epidemic. Teledentistry can be used for informational purposes, consultations, and triage, enabling healthcare professionals to let patients know whether they need urgent or emergency care for their dental concerns, whether a condition could be temporarily relieved at home, or whether treatment could be put off. Teledentistry can assist reduce the pressure of patients seeking dental care at overburdened emergency departments and urgent dental care settings when many dental clinics are closed and most individuals are remaining at home. When members of the dental team are able to deliver such services in public spaces, like schools, without onsite dentist supervision, teledentistry can also be utilised to facilitate access to preventative care and oral health education.

Prior to COVID-19, many states imposed legislative restrictions on the use of teledentistry and restricted public and private insurance reimbursement. Many medical and behavioural health professionals have fewer stringent rules and insurance reimbursement guidelines regarding telemedicine than dentists do. It was stated clearly in a Washington Post article that “Telemedicine was essentially ready for the inflow.” On the other side, teledentistry was compelled to catch up. After the pandemic, we advise lawmakers, regulatory bodies, and third-party payers to take into consideration making the interim revisions to teledentistry rules that were spurred by COVID-19 permanent in order to enable wider access.

Implications for Public Health Practice: Dental Public Health’s Roles

Health disparities can be prevented and are unfair. Despite spreading to people throughout the world, SARS-Cov-2 has disproportionately impacted the most vulnerable. People in the United States who lack access to quality healthcare, wholesome food, and a secure environment, as well as those who have underlying medical concerns, live in close quarters, have lost their jobs, or are homeless, are particularly at risk and more likely to contract the virus. It is time to acknowledge socioeconomic determinants of health and address racism, systemic injustice, and unfair conditions.

Disparities and injustices in oral health are a component of a bigger, cultural picture. The victim has frequently been blamed. According to health journalist Mary Otto, who also wrote the ground-breaking book Teeth, “We virtually see dental degeneration through a moral lens. As opposed to those who are afflicted with an illness, we view those who have an oral disease as moral failures. The phrase “perfect storm” in oral health care in the United States may not be overstated when used to describe pandemic-related events. Risk factors are increased, access is restricted to the most vulnerable, safety issues are increased, and the economy poses significant difficulties for both patients and providers. The issue has highlighted the difficulties and prospects for oral health care in the United States. The effects of COVID-19 are particularly severe for vulnerable people. Clinicians of oral health care and advocates for the field must now effectively convey the connection between oral health and overall health, outline the precautions being taken to protect both patients and providers and push for preventative measures and non-aerosolizing procedures (Table 2). Policy considerations, ongoing research, monitoring, surveillance, and other elements of health should all take oral health into account. The temporary regulatory reforms being adopted to handle the current crisis, guarantee access to oral health care, reduce disparities and inequities, and promote population health must be made permanent through advocacy.