22 minute read
Dentistry's Collective Strength During Unprecedented Times
Richard J. Nagy, DDS, a board-certified periodontist and diplomate of the American Board of Periodontology, maintained a private practice in Santa Barbara, Calif., before becoming the director of the postgraduate periodontics residency program and department chairman at the Greater Los Angeles VA Healthcare System in 2020. He is the former editor of Periodontal Abstracts and past president of the California Society of Periodontists, the Western Society of Periodontology and the California Dental Association. Conflict of Interest Disclosure: None reported
It was March 7, 2020, and the first California Dental Association Board of Trustees meeting of the year had just been adjourned. The typical business of the association was conducted and plans were laid out for the year ahead; however, it was becoming evident that a probable pandemic was looming.
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Preparations were underway, and CDA had already formed two COVID-19 workgroups to address the unknowns that were sure to be arising. Soon after that meeting, it felt like all of a sudden, a distant tidal wave came crashing to shore.
One of my favorite John Lennon quotes, “Life is what happens when you’re busy making other plans,” meant more in that moment than ever before. CDA’s dentist leaders and professional staff immediately got to work to address the new events and issues that seemed to come forward daily. There wasn’t an instruction manual to guide dentistry through a pandemic, but it was the collective strength of CDA that helped create solutions.
One of the first issues to address in the face of this potentially deadly airborne virus was how to ensure safety in dental offices when very little was known about the virus. Therefore, early on, dental offices were advised to limit patient care to emergencies only for what was thought would just be a few weeks. Then, on March 19, California Gov. Gavin Newsom issued an order for “all individuals living in the state of California to stay at home or at their place of residence,” with exceptions for critical service sectors, and soon after, the California Department of Public Health (CDPH) mandated that all health care facilities postpone routine and elective care and treat medical and dental emergency needs only. Never did anyone think this would last for several months. CDA stepped up to provide meaningful leadership and advocacy during that time, working with the CDPH, the California Occupational Health and Safety Administration (Cal/OSHA) and the governor’s office to provide guidance for patient and practitioner clinical safety and dental practice support.
This paper describes the work of CDA in meeting the profession’s needs, the strength organized dentistry was able to leverage in a variety of venues and the ability of the organization to nimbly adapt, pivot as needed and respond to the ever-changing challenges presented by the COVID-19 pandemic. FIGURE 1 reflects the timing of major events. However, this paper discusses the topics that concerned most California dentists around these events.
Working To Get Dentistry Reopened Safely
As scientists and health experts worldwide worked to learn more about the virus, CDA quickly mobilized leadership and resources to help dentists get back to practice as safely and as quickly as possible. Two COVID-19 workgroups — Clinical Care and Economic Recovery — were appointed to sort through the science and economics and to lead the way in answering the pressing questions: What do dentists need and how can CDA help provide it?
Dr. Richard Nagy, CDA president in 2020, and State Dental Director Dr. Jayanth Kumar co-chaired the Clinical Care Workgroup, and along with representation from practicing dentists, dental school deans and educators and dental hygiene and dental assisting, worked to understand the evolving science. The workgroup developed an entire suite of resources known as “Backto-Practice,” including training videos, easy-to-use flowcharts and checklists, and along with CDA’s Practice Support experts created a resource library that also included assistance with employment questions, patient communications and navigating economic relief options. These resources have more than 375,000 page views on CDA’s website.
These efforts added to those that already existed within CDA’s Practice Support, where staff provide members free and unlimited access to expertise and resources on the following four areas of dental practice: dental benefits, regulatory compliance, employment and practice management. During the first year of the pandemic, Practice Support staff continued providing one-on-one guidance to dentists via email and phone, logging more than 8,000 unique member contacts in 2020. What’s more, throughout the pandemic, Practice Support staff provided numerous resources and continuous interpretation of the ever-evolving guidance from the Centers for Disease Control and Prevention (CDC), the CDPH and Cal/ OSHA to ensure dentists could practice safely and maintain compliance.
Dr. Kumar’s 2015 appointment as California state dental director and the creation of a high-functioning state oral health program were top priorities of CDA’s Access to Care Plan goals and the result of significant advocacy. Though it was clear the state needed strong dental public health leadership to achieve improvements in population oral health, it was difficult to imagine how important the state dental director’s role would be in a pandemic. Working closely with Dr. Kumar, CDA leaders and advocacy staff were able to represent at the highest levels of government what dentists were experiencing and create back-to-practice resources that were practical and effective.
Clear, dental-specific guidance was essential, as during the early stages of the pandemic numerous agencies, including the World Health Organization (WHO), the U.S. Occupational Health and Safety Administration (OSHA) and the CDC, were all issuing guidance for health care providers. As much of it was focused on hospitals and others treating patients who were ill, dental practices needed guidance specifically for providing oral health care in the pandemic. This made good communication with the CDPH and Cal/OSHA essential. On May 7, 2020, the CDPH released guidance specifically for dental practices returning to routine care, including specific criteria regarding local infection rates, PPE requirements, COVID-19 screenings for patients and infection control clarifications from the CDC, among other topics.
Additionally, local, county and city governments responded with their own ordinances on mask wearing, social distancing and eventually vaccination and testing, adding confusion about where to look for appropriate guidance. CDA monitored local public health ordinances and mandates in all 58 California counties and provided education and clarification for members to ensure compliance with all applicable rules (FIGURE 2).
What’s more, early in the pandemic, there was a quick pivot to digital-first communications versus print to ensure that dentists would receive the most up-to-date, accurate information because news was evolving quickly and at times so quickly that there were multiple updates within a day. Almost immediately after shelter-in-place orders were implemented, the COVID-19 Information Center was created and located on cda.org to provide resources on precautions and compliance. Additionally, a weekly president’s informational video, a COVID-19 newsletter to share latest news updates, Practice Support resources and educational opportunities were developed.
Not long after, “virtual membership meetings” were introduced to answer dozens of member dentists’ questions related to practicing during the pandemic, including personal protective equipment (PPE) and infection control requirements, advocacy efforts, testing, patient management and other topics. Afterward, Facebook Live events were launched to quickly share with dentists the latest on PPE efforts, employment law guidance as employees were returning to work and financial relief grant and loan programs.
Addressing the PPE
Shortage As experts confirmed the risk of SARS-CoV-2 infection through respiratory transmission, proper airway protection became essential for dental office personnel. This meant the use of properly fitted N95 respirators or similar or higher levels of respiratory protection for all clinical dental staff. However, N95 shortages occurred almost immediately, as the need within health care exploded at the same time that production stalled and supply chains clogged. Emergency-use alternatives were described by the CDC, and dentistry implemented the extended and reuse of N95s, purchased KN95s and in some cases tried to adapt personal airpowered respirators (PAPRs) for dental treatment. Even when N95 or KN95s could be found, the requirements for medical evaluation and fit testing posed challenges to quickly meeting these new respiratory protections for dentistry.
To directly assist dentists with respirator shortages, CDA and The Dentists Supply Company (TDSC) worked with the governor’s office to procure millions of N95s from a state stockpile in Fresno, California. TDSC, which was launched in 2017 as a subsidiary of CDA to provide members with an online marketplace of discounted dental supplies, was the perfect partner to manage, track orders and distribute these respirators quickly and efficiently to dentists throughout California. Trucks were sent to Fresno to pick up supplies and bring them to the TDSC distribution center in Reno, Nevada. All were excited to let dentists know that these precious respirators were ready to be distributed. Then, hours before dentists were to be informed and distribution to begin, the state took back the N95s. Needless to say, disappointment and frustration ensued, but the work to find more respirators and other PPE had to continue. Later, two massive distributions of state-supply PPE were acquired and distributed to California dentists via TDSC.
Local dental component societies were also instrumental in locating, securing and distributing PPE, often working with county authorities to secure supplies for dentists. As acquiring PPE was especially difficult during the earliest months of the pandemic, TDSC learned to be critical and scrutinize the quality of available PPE amid concerns that global supplies increasingly included counterfeit products that risked failing required safety standards. Searching for safe PPE continued into 2021 when CDA partnered with the California Medical Association to help further distribute PPE from the state stockpile at only the cost of shipping. To date, over 25,000 PPE kits worth more than $11.5 million have been distributed to dentists.
Though respirators were the earliest source of PPE strain on dental practices, gloves and gowns quickly followed, as the slowdown in production and distribution channels affected all types of PPE. As expected, increased demand and decreased supply led to steep price increases, and dentists found themselves paying up to 10 times more for these items than before the pandemic.
Although TDSC transitioned to a new parent company, Henry Schein, in 2020, its original mission to serve state dental association members with everyday low prices for dental supplies was birthed by CDA’s commitment to assist dental practice success by lowering operating costs and successfully saved member dentists over $5 million in its early years. That it became an important partner for securing and distributing PPE during the pandemic was not something CDA could have anticipated but was certainly a plus for California dentists.
Besides assisting dentists with PPE, CDA proactively communicated with state regulators to ensure they understood dentistry’s exceptional history of preventing disease transmission during the provision of dental care and successfully advocated to provide clear infection control and safety protocols that would get dentists back to work quickly and safely during the pandemic.
Assuring Patient Confidence in Returning to Dental Care
Additionally, CDA sponsored “Keep Smiling California,” a dental health awareness campaign to provide information to patients and build their confidence to return to the dentist. This included consumer research to gauge patient comfort with visiting the dentist during the pandemic. From these findings and the increase in misinformation about dental office safety, it became very clear that something needed to be done to let patients know that it was safe to go to the dentist. Therefore, statewide media interviews were conducted by CDA member dentists to educate the public on the safety and importance of dental care during the pandemic. This helped to further establish public awareness about the safety of dental care through well known, respected and widely viewed media including “Good Morning America,” The Washington Post, National Public Radio, several statewide newspapers and local television and radio outlets.
Helping To Solve Workforce Challenges
When dental practices were advised to provide only emergency treatment in the first few months of the pandemic, practice owners were faced with how to address their employees’ work status. Some terminated all staff and paid out remaining benefits, but most of the time, staff who could work from home did and others were placed on “furlough.” During this period, communication between employers and employees was essential, as there were times when furloughed staff were asked to return to the office to assist in providing immediate palliative or emergency care. CDA assisted dentists who had to furlough employees with resources on required documentation (e.g., sample furlough letter) and how to stay connected to their teams through social and communication channels.
Naturally, employees had many questions too, and CDA’s Practice Support experts provided a wealth of HR guidance, including links, tips and webinars for employers and employees on Pandemic Unemployment Assistance (PUA) benefits, Supplemental Paid Sick Leave benefit laws and the complex benefits employers could offer employees who were affected by COVID-19 through illness, exposure or caretaking.
At the statewide level, Dr. Natasha Lee, CDA past president, dental educator and private practice owner, was appointed to the Governor’s Task Force on Business and Jobs Recovery to ensure dentistry’s concerns were represented with state economic and workforce agencies. Dental office staff shortages, especially for dental assistants, which had been an issue prior to the pandemic, became a significantly greater issue during the pandemic. A CDA economic recovery workgroup was developed that focused on increasing awareness of dental careers and recruitment.
Furthermore, the pandemic caused a significant amount of job loss in the restaurant, retail and travel industries. Recognizing that the service orientation and people skills required for jobs in these fields were well-suited for dental assisting and those recently unemployed may be interested in retraining, CDA worked with state workforce experts on plans to recruit and retrain interested individuals. In the last quarter of 2020, CDA executed three strategies to support members in this area, including a dedicated marketing and PR campaign focused on stimulating interest in a career in dental assisting, intensive curriculum development focused on dental assistant training and the launching of a new career center on cda.org to connect member dentists with job seekers. Included in the marketing campaign, “SmileCrewCA. com” was created to allow interested individuals the opportunity to learn more about a career in dental assisting as well as submit their information for interest in the training program. Since this launch, CDA has piloted four dental assisting training bootcamps in the Bay Area and San Diego, with additional locations on the way.
Supporting Financial Relief Efforts
CDA’s usual focus on the state legislative and regulatory environment quickly expanded to include both federal and local efforts as all levels of government frantically responded to the pandemic. Congress passed multiple rounds of economic stimulus packages in 2020, including the Families First Coronavirus Response Act (FFCRA) and the $2.2 trillion Coronavirus Aid, Relief and Economic Security (CARES) Act, both signed into law in March 2020. These bills included direct payments to individual taxpayers, small business loans, vaccine response and development and PPE purchasing and manufacturing as well as paid sick leave and unemployment benefits for workers and families. Additional legislation through 2020 and 2021 extended programs and provisions of the CARES Act and implemented additional relief packages.
The small business loans available to dentists included the Economic Injury Disaster Loan (EIDL) and Paycheck Protection Program loan (PPP). The rules and requirements, application processes and deadlines unfolded as the federal government worked to quickly implement these programs. CDA provided feedback to Congress and federal administrators where possible to get stimulus easily and quickly to dental offices, and Practice Support staff advised dentists on the changing and often confusing requirements for each phase of these programs.
The Provider Relief Fund (PRF) was also established by Congress through the Department of Health and Human Services to help health care providers suffering economic losses due to COVID-19. These funds initially targeted Medicare and Medicaid providers, with additional rounds of funding being opened to all dentists, newly practicing dentists and rural dentists. In total, the four phases of PRF made $117.5 billion available to health care providers including dentists. Legal analysis along with robust communication to members was essential to keep dentists and their offices up to speed with new rounds of funding, loan opportunities, extended deadlines, evolving compliance requirements and changing requirements for sick leave and unemployment.
CDA received numerous calls and emails from financially stressed member dentists early in the pandemic and took quick action to develop programs and options that would provide guidance and relief. Among those were extending the membership dues grace period, waiving fees for CDA online continuing education, providing no-cost access to audio recordings from prior CDA Presents events, and with Bank of America, one of CDA’s endorsed partners, allowing dentists to defer loan payments.
Further, The Dentists Insurance Company (TDIC), CDA’s insurance subsidiary, understanding concerns related to lost income from office closures and other pandemic related challenges, quickly offered dentists economic relief and guidance. This included such things as issuing policyholders nearly $6 million in premium refunds in 2020, reducing fees for online risk management seminars and temporarily waiving fees for credit cards and insufficient funds. Furthermore, TDIC sponsored financial health webinars featuring expert speakers plus one-on-one guidance. These actions helped to keep dentists adequately covered and able to continue providing care as the profession adjusted to the financial havoc the pandemic created on all sectors of society.
Advocating for Dental Benefits Reimbursement
CDA also worked with dental benefits companies to secure relief and financial support for dentists. As part of this advocacy, CDA successfully sponsored legislation (SB 242) to require private health care plans to reimburse contracting health care providers for their business expenses to prevent the spread of respiratorytransmitted infectious diseases causing public health emergencies declared on or after Jan. 1, 2022. Though this could not be retroactive to COVID-19, should dentistry face another similar pandemic, costs incurred by dental practice owners for respiratory protection, such as N95s, would be reimbursable.
Through that work, seven grassroots action campaigns were organized for varying COVID-19 relief efforts, with more than 7,180 CDA member dentists and advocates responding to CDA’s request to send communication to lawmakers requesting passage of COVID-19 relief legislation affecting dentistry. Successful advocacy efforts also turned a potential loss of Proposition 56 funding (California’s Healthcare, Research and Prevention Tobacco Tax Act of 2016) into a win, which resulted in preserving the state’s dental student loan repayment program, State Office of Oral Health funding and Medi-Cal Dental Program provider supplemental payments.
Supporting Students and New Dentists
The pandemic not only disrupted dental practices, but also created a bottleneck for dental students on the precipice of graduation. With so much still unknown about the virus, nearly all dental schools in the country canceled the patient-based examinations required for licensure in California. In turn, all major dental examining agencies began to offer mannikin-based examinations. However, the Dental Board of California remained uncertain that it could accept test results from a new examination method without legislative action.
The time was certainly ripe for California to move away from patientbased exams. Many educational and student groups have long advocated for the elimination of patient-based examinations due to the ethical and financial issues associated with obtaining patients with qualifying oral disease and the continuation of that care beyond the date of examination.
CDA worked closely alongside California’s dental schools, successfully advocating to secure a timely pathway for dental licensure for 800-plus dental students graduating during the pandemic. The results of this advocacy will be long lasting, as the state will now permanently accept mannikin-based examinations in addition to patient-based exams.
Because of this, CDA was honored with a Gies Award for achievement by a public or private partner. Given annually by the American Dental Education Association Gies Foundation, the Gies Award honors individuals and organizations that exemplify the highest standards in oral health and dental education, research and leadership.
Providing Continuing Education and License Renewal Support
With various shelter-in-place orders executed throughout the state, the ability for dental health professionals to attend in-person continuing education courses was drastically reduced, putting licensees in jeopardy of failing to meet licensure renewal requirements and preventing them from continuing to practice and provide care to patients. CDA responded to this concern with successful advocacy that gave all health care licensees an adequate extension to complete C.E. units for renewal and a waiver to allow virtual courses to meet the requirements for live C.E. for the duration of the governor’s declared state of emergency. Additionally, CDA continued to provide educational content to members despite the cancellation of CDA Presents in 2020. While a large, in-person event was unsafe to host at the time, CDA pivoted its offerings to include over 20 live and recorded webinars on dentistry and COVID-19 to help dentists navigate practicing in the pandemic. Further, the semiannual CDA Presents was adapted into a virtual convention with over 40 C.E. courses and an interactive exhibit hall that was attended by more than 5,700 attendees. This experience challenged past views of educational offerings and propelled CDA to prioritize accessible resources for all members through various online and hybrid learning opportunities.
Evaluating COVID-19 Testing Feasibility in Dental Practices
In California, COVID-19 testing is within the scope of practice for dentists when used for screening for COVID-19 rather than for providing a formal COVID-19 diagnosis. However, in order to conduct a rapid, in-office COVID-19 test, a dentist must first obtain Laboratory Field Services (LFS) testing licensure required by the state and Clinical Laboratory Improvement Amendments (CLIA) licensure required at the federal level. Prior to the pandemic, dentists were not eligible to apply for state lab licensure despite being eligible at the federal level. CDA quickly worked with the state legislature to sponsor a bill that created parity with state and federal law and ultimately permitted dentists to conduct rapid testing on both patients and staff.
However, it was not always certain whether testing technology would advance sufficiently to provide dental settings with a test that was rapid enough to screen real time and sensitive, accurate and affordable enough to provide to all patients. Eventually, a handful of rapid tests became available to health care providers; however, while the tests were fast, they were still unable to detect infection within the first few days of exposure, making testing still inadequate to ensure a patient’s COVID status and eliminate any PPE requirements.
Complicating matters, as the state began to reopen in 2020, and prior to the approval and availability of rapid tests, many local health departments considered mandating negative test results prior to obtaining dental services. Because dentists were not yet able to obtain lab licensure and test results were typically obtained one to five days after specimen collection at community testing sites, this requirement would have posed a significant barrier to care. CDA and local dental societies successfully advocated against these proposed requirements so that dentists could continue to screen patients through temperature checks and previsit questionnaires.
Appropriately screening patients for infectious disease prior to performing dental treatment is the standard of care and a Cal/OSHA requirement; though absent federal or state guidance, determining how that screening occurs and whether to implement in-office rapid tests remains at the dentist’s discretion. However, the state’s decision to issue public health orders requiring dental office staff to either provide proof of COVID-19 vaccination or submit weekly negative COVID-19 tests to their employer has created an additional need for dental offices to have the option to test on-site.
Further, while testing patients directly assists dentists with dental treatment or referral decisions, it has the additional advantage of identifying potentially positive individuals early in the disease process, facilitating referral to a medical professional for diagnosis and intervention and contributing to public health surveillance and contact tracing efforts.
Defining Dentistry’s Role in Vaccination Efforts
Once COVID-19 vaccinations became available, the state had to manage a shortage of doses against an increasingly large group of employees advocating for front-line worker status. From hospitals to grocery stores, nearly all industries were seeking prioritized access to vaccine doses. Initial rollout plans for vaccines did not include dental offices in parity with physician offices or hospitals. CDA’s participation in a statewide community vaccine committee led by the state epidemiologist in addition to successful CDA advocacy secured not only priority access to COVID-19 vaccines for dentistry, but also obtained an emergency waiver for dentists, hygienists and dental students to serve as temporary vaccinators, largely at mass vaccination sites and at some dental schools.
What’s more, CDA successfully sponsored legislation to permanently codify this scope expansion for dentists to also include flu vaccines. At the same time, partnership with the CDPH and the Office of Oral Health has led to creating vaccine confidence resources and tools to increase vaccination rates among dental teams and patients. Part of this work included a vaccine confidence survey, which resulted in findings that as of July 2021, 94% of dentists in California were vaccinated, making California dentists the most vaccinated group of health care professionals in the country.
Conclusion
Only the highlights of the extraordinary amount of work completed through organized dentistry by CDA volunteer leaders in collaboration with CDA staff during the COVID-19 pandemic have been presented here. There was a great amount of additional time and effort invested behind the scenes, work which continues today. Thank you to the countless individuals who gave their time and expertise, for together it made a difference for dentists, their teams, their patients and their practices. CDA’s continued, proven support of the profession serves as a case study for the value of organized dentistry. CDA’s mission throughout the COVID-19 pandemic is the same as it’s been for over 150 years: To be limitless in our support and advocacy for our members. Together through strength in numbers, our 27,000-member strong California Dental Association continues to pave the way forward for the profession of dentistry and the oral health of Californians.
ACKNOWLEDGMENT The author thanks CDA staff in Public Affairs and Practice Support for their contributions.
THE AUTHOR, Richard J. Nagy, DDS, can be reached at nagyperio@gmail.com.
