Oral Health and COVID-19: Increasing Prevention and Access

Going Forward: Opportunities

Focus on Prevention and Promote Nonaerosol-generating Dental Procedures

Prevention is a cornerstone of public health. The COVID-19 pandemic presents an opportunity for the dental profession to shift from an approach focused on surgical intervention to one emphasizing prevention. Embracing nonsurgical, nonaerosolizing caries prevention and management will be critical in this endeavor. The profession has always supported community water fluoridation, and dental hygienists are considered prevention experts.[34,35] However, the dental compensation model is based on providing expensive, restorative procedures that are financially out of reach for many people.

Guidelines have been developed to shift the dental care paradigm to a more preventive focus.[36–40] Strategies include reduction in common risk factors such as tobacco and alcohol use, promotion of a healthy diet low in sugars, community water fluoridation, topical fluorides, and promotion of oral health in community settings. These oral health messages and interventions should be integrated into medical sites such as primary care and pediatric offices. Prevention and nonsurgical caries management include many options. Evidence-based materials include dental resin sealants, glass ionomers as sealants or as part of atraumatic restorative treatment performed with hand instruments, silver diamine fluoride, sodium fluoride varnish, and other self-applied and professionally applied topical fluorides.[40–42] These materials can be applied without generating aerosols, reducing the risk of viral transmission. These methods present a major opportunity to expand access to preventive and restorative care for vulnerable populations, particularly when combined with policy changes increasing hygienists’ scope of practice, sustainable payment reform, and changes in the education of oral health professionals.

Providers and payers together have a responsibility to shift toward preventive care, particularly as COVID-19 threatens to increase disparities in oral health care access for the United States’ most vulnerable populations. Before the pandemic, Birch et al noted that a review of provider and payer practices made clear that “further work was required on both the provider and payer side to ensure that evidence-based prevention was both implemented properly but also reimbursed sufficiently”.[43] As health care compensation moves toward value-based care and a focus on health outcomes, prevention and maintaining oral health and sound tooth structure will shift reimbursement away from the current expensive model of reimbursement for restoration of tooth structure and function.[44] In particular, reimbursement policies, which traditionally have incentivized surgical, high-end restorative procedures like crowns and multisurface fillings, must be revisited to prioritize preventive and nonsurgical, nonaerosolizing treatments and make them more financially sustainable.

Improve Communication

Communications concerning patient and provider safety are critical.[45] Surveillance and monitoring are needed to confirm whether transmission of COVID-19 occurs in the dental office. According to CDC,[27] “There are currently no data available to assess the risk of SARS-CoV-2 transmission during dental practice.” The availability of PPE for dental care should be monitored, and the effectiveness of various types of PPE should be determined. Many oral health care providers are anxious about returning to work, and many patients may be hesitant to enter a dental office. Communication and clarity are critical, especially with low-literacy populations. Messaging should include the importance of maintaining good oral health and its role in overall health.

Protect and Enhance Medicaid Reimbursement

Dental coverage under Medicaid is mandated for children, but state Medicaid programs’ approaches to oral health services for adults vary significantly, especially in terms of the comprehensive nature of such services (Figure). Only 19 states have “extensive” Medicaid dental benefits for adults.[46] Among US adults aged 19 to 64, only 7.4% have Medicaid dental benefits and, alarmingly, 33.6% have no dental insurance benefits.[47] The fiscal solvency of dental safety-net clinics will thus remain critical to serving at-risk populations during and after the pandemic. These sites will be needed more than ever, as delayed and postponed treatment increases need for more extensive and urgent care.

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Figure.

Extent of Medicaid adult dental benefits, by state. Source: Center for Health Care Strategies (46).

It is widely documented that during economic downturns, Medicaid enrollment increases.[48] With unemployment increasing at an unprecedented rate, we can reasonably anticipate the same effect in this pandemic. During times of state budget cuts, dental Medicaid coverage is often at risk.[49] In the immediate aftermath of the Great Recession during state fiscal years 2010 through 2012, 19 states reported restrictions in Medicaid adult dental benefits.[50] Amidst the pandemic, many states have modified public payment policies to meet the demand of their most vulnerable residents, and it will be important that advocacy efforts secure continuity of these provisional changes. However, given current circumstances, it is imperative that policy makers consider expanding adult dental benefits under Medicaid rather than reducing them. Access disparities will likely increase without expansion of dental benefits under Medicaid.

Ease Dental Workforce Restrictions

Guidance for dental practice during COVID-19 continues to evolve, and regulations vary by state.[51] As dental care resumes, it is critical that workforce policies and licensure scope are evaluated to address workforce utilization bottlenecks to respond to communities’ needs more effectively and efficiently.

As of 2019, 11 states did not allow for some form of direct access to preventive oral health services by a dental team member outside of the dentist’s supervision.[52] In these states, a dentist must perform an examination before delivery of preventive care by a hygienist. Easing scope of practice and workforce restrictions would increase access to care. Increasing opportunities for dental team members like dental therapists, community dental health coordinators, and expanded function dental assistants — all currently in limited supply and restricted by dental practice acts in many states — would help bring needed, more affordable services to underserved communities.

Advance Teledentistry to Address Access Gaps

The COVID-19 pandemic has thrust alternative modalities such as teledentistry to the forefront of policy considerations.[53] Teledentistry supports the delivery of oral health services through electronic communication means, connecting providers and patients without usual time and space constraints. Teledentistry’s unique ability to connect disadvantaged, primarily rural communities and the homebound with dental providers[54] makes this method particularly well-suited to address lack of access during and after the pandemic.

Teledentistry can be used for education, consultation, and triage, allowing providers to advise patients whether their dental concerns constitute a need for urgent or emergency care, whether a condition could be temporarily alleviated at home, or whether treatment could be postponed. When many dental offices are closed and people are largely staying at home, communication and information via teledentistry can help lessen the burden of people seeking dental care at overwhelmed emergency departments and urgent dental care settings. In more usual circumstances, teledentistry can also be used to facilitate access to preventive services and oral health education when members of the dental team can provide such services in community settings, such as schools, without onsite dentist supervision.

Before COVID-19, many states inhibited use of teledentistry through legislative barriers and limited public and private insurance reimbursement. Compared with dentistry, many medical and behavioral health providers have less restrictive regulations and insurance reimbursement policies concerning telehealth. A Washington Post report[55] was clear: “Telemedicine was largely ready for the influx.” Teledentistry, on the other hand, was forced to play catch-up.[56] Emergency reimbursement changes prompted by COVID-19 have brought relief, but post-pandemic, we recommend that legislators, regulatory authorities, and third-party payers consider making permanent the temporary modifications to teledentistry policies to support increased access.

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