The WVU School of Dentistry Experience During the Coronavirus Shutdown – Dr. Juan M. Bugueno and colleagues

Response to the COVID-19 Outbreak: The West Virginia University School of Dentistry (WVU SOD) Experience During the Coronavirus Shutdown. Dr. Juan M Bugueno, Dr. Fotinos Panagakos, Dr. Steven B Whitaker, Dr. Mark Byron, Dr. Tammy Chipps, Dr. Arif Salman Abdul Shakore, Dr. Phillip Nguyen, Dr. Bruce V Shipe, Donna V Haid, Leslee Tyler

ABSTRACT

Based on the rising number of COVID-19 cases in the U.S., on March 10, 2020 WVU suspended in-person classes and offered online classes to begin on March 30. On March 16, the WVU SOD postponed all elective treatment. The urgent care, endodontic and oral surgery clinics remained open, providing emergency services. On March 17, the first COVID-19 case was reported in WV, and two days later, the first case in Monongalia County. As of June 16, 2020, 131 cases with laboratory-confirmed COVID-19 infection had been detected in this county, of which five cases had died. In dental settings, the risk of cross infection is high between dental practitioners and patients. WVU SOD reacted immediately, and a COVID-19 Task Force was set up and initiated a response framework to prevent and safeguard students, residents, faculties, staff and patients from COVID-19 infection.

Objectives:

1. Describe demographic and clinical characteristics as well as the resolution of urgent care services provided at WVU SOD between March 16 and May 15, 2020.
   
   
2. Present our response including clinical protocols, triage of urgent care patients, urgent procedures, infection control guidelines, and human resources during this global health emergency.

The COVID-19 pandemic has collectively and individually challenged all healthcare professionals. By implementing a tailored response, each health care facility might be able to overcome the crisis while minimizing bad outcomes. In sharing our experience at WVU SOD, we hope that other dental facilities facing similar or future emergencies can enhance their preparedness to safeguard health care providers and patients.

On December 31, 2019, The World Health Organization (WHO) was notified of several pneumonia cases of unknown cause in Wuhan City, China.¹ Soon thereafter, Chinese authorities isolated a new type of coronavirus and shared the genetic sequence with other countries for use in developing specific diagnostic kits. This new agent was identified as a novel coronavirus (2019-nCoV), the seventh member of the coronavirus family known to infect humans.^{1, 2} The International Committee on Taxonomy of Viruses designated the virus “SARSCoV-2,” according to the virus’ phylogenetic and taxonomic assay. On January 30, 2020, the WHO declared this pneumonia outbreak a public health emergency of international concern and advised the People’s Republic of China and the global community on measures to control the outbreak.³ On February 11, 2020, the WHO announced a name for the new coronavirus disease: COVID-19.^{2, 4,5} Due to the alarming levels of spread and severity of illness, as well as serious levels of inaction by the global community, the WHO declared the COVID-19 outbreak a global pandemic on March 11, 2020.⁶

On January 21, the Centers for Disease Control and Prevention (CDC) and Washington State Department of Health announced the first case of COVID-19 in the United States. The patient, a 35-year-old male, had spent time in Wuhan and returned to the U.S. on January 15. On January 19, he became ill and sought care at a local medical facility. Based on his travel history and symptoms, healthcare professionals assumed the patient to be infected with SARSCoV-2. A clinical specimen was collected and sent to CDC overnight, where laboratory testing confirmed the diagnosis via CDC’s Real-time reverse transcription-polymerase chain reaction test. ^7-9 The CDC then deployed a team to trace the patient’s close contacts to determine if others had become infected.

On January 31, 2020, the U.S. declared a public health emergency and restricted entry into the country, including a mandatory 14-day quarantine for people returning from Hubei province. Since then, cases have occurred in all 50 states and all inhabited territories except American Samoa. Further, all 50 states have received disaster declarations from the federal government. As of June 23, 2020, the U.S. death rate from COVID-19 was 327.17 per million people, the seventh highest rate globally.¹⁰

In response to the pandemic, on March 16, the governor of WV declared a State of Emergency for all 55 counties. The next day, the first WV case was reported and two days later, the WV Department of Health and Human Resources (DDHR) documented the first COVID-19 case in Monongalia County, the home of West Virginia University. The DDHR then followed with written directives for all health care providers to discontinue the delivery all non-emergent, non-urgent procedures by March 24, 2020.” The DHHR provided guidelines to determine what is emergent, urgent, or non-urgent, and urged the use of telemedicine services where clinically possible ⁸. As of June 23, 2020, 2,582 cases have been reported in the state, of which 92 cases have resulted in death. As of the same date, Monongalia County has reported 144 cases with five fatalities. ¹¹ As of June 16, 2020, a total number of 2,302,288 cases of COVID-19 has been reported in the U.S., with 120,333 deaths.¹²

On March 16, 2020, the American Dental Association (ADA) recommended dentists nationwide postpone elective procedures for the ensuing three weeks. The ADA emphasized that concentrating on emergency/urgent care would alleviate the burden that dental emergencies would place on hospital emergency departments.¹³ Subsequently, due to a rise in COVID-19 transmissions and the most recent CDC’s recommendations, the ADA extended their guidelines for emergency-only care until April 30, 2020. ¹⁴

Amidst the landscape of rising COVID-19 cases and emerging federal and state guidelines, West Virginia University (WVU) suspended in-person classes on March 10 and offered online class instruction to begin on March 30. On March 16, the WVU School of Dentistry (SOD) postponed all elective treatment. The urgent care, endodontic and oral surgery clinics remained open, providing emergency services.

COVID-19 TRANSMISSION RISKS IN HEALTH CARE PERSONNEL

Health care personnel (HCP) are deeply affected by the COVID-19 pandemic. As of April 9, 2020, 9,282 US HCP with confirmed COVID-19 had been reported to CDC. As only 16% of patients with COVID-19 disclosed their occupation, this data is likely underestimated. HCP with mild or asymptomatic infections were also less likely to be tested, thus less likely to be reported. Nationally, only 3% of reported cases by April 9 were among HCP. However, in states with more complete reporting, HCP accounted for up to 11% of cases. The total number of COVID-19 cases among HCP is expected to rise as more communities experience widespread transmission.¹⁵
Even higher numbers of COVID-19 among HCP have been reported in Italy. As of April 7, 2020, the Italian National Institute of Health reported 13,121 cases of COVID-19 infections among HCP, the highest of any occupational category. Moreover, during the month of April, 2020 the Italian National Federation of Medical Doctors and Dentists reported the deaths of 86 physicians and eight dentists from to COVID-19.¹⁶

Data from Wuhan shows how healthcare facilities can be a source of COVID-19 spread. Between January 23 and February 4, 2020, the School and Hospital of Stomatology at Wuhan University reported nine HCP with a confirmed COVID-19 diagnosis.¹⁷ During the month of January 2020, a single hospital in Wuhan cared for 138 patients with COVID-19 pneumonia. Fifty-seven (41.3%) were presumed to have been infected in hospitals, including 17 patients (12.3%) already hospitalized for other reasons, and 40 HCPs (29%). Of the infected HCPs, 31 (77.5%) worked on general wards, 7 (17.5%) in the emergency department, and two (5%) in the ICU. This data reinforces the concept that close contact with positive patients, whether symptomatic or not, exposes HCP to a higher risk of infection.¹⁸

The Occupational Safety and Health Act (OSHA) has divided job tasks into four risk exposure levels to COVID-19: very high, high, medium, and lower risk. The Occupational Risk Pyramid displays the four exposure risk levels to represent probable distribution of risk. HCP, including dentists, have high potential for exposure to known or suspected sources of COVID-19 during specific clinical procedures, and thus are located at the top of the pyramid.¹⁹ Furthermore, a March 15, 2020 New York Times’ article titled “The Workers Who Face the Greatest Coronavirus Risk,” highlights that since dental professionals work in close proximity to one another and their patients, they confront diseases and infectious agents on a daily basis.²⁰

As this illness is still novel and the outbreak rapidly advancing, overall figures on clinical experience in the dental transmission of COVID-19 are still scarce. However, given the mechanisms of transmission and high transmissibility of the disease, dental professionals seem to be at high risk of infection due to exposure to saliva, blood, and aerosol/droplet production during numerous dental procedures. The generation of aerosols facilitates the contamination of the environment, dental instruments and surfaces. It is critical to remember that the virus can survive on hands, objects or surfaces that were exposed to infected saliva for up to nine days.^{2, 17} Additionally, blood and saliva have been recognized as a potentially high-risk route of COVID-19 infection when they come into direct contact with the mucosa of the oral and nasal cavities.^{2, 16, 17, 21-23}

In one study, virus was detected in self-collected saliva from 91.7% (11/12) of patients with laboratory-confirmed COVID-19 infection.²⁴ Another showed declines in salivary COVID-19 RNA levels in serial saliva specimens after hospitalization. Culture demonstrated that live virus was present in the saliva of three patients, some days after being discharged from the hospital. Moreover, salivary gland epithelial cells can potentially be infected with COVID-19 and become a major source of the virus in saliva.^22-25

As part of the national COVID-19 strategy, the WVU SOD took action to safeguard students, residents, faculty, staff and patients from the high-risk environment for virus transmission. The dean of the SOD appointed a task force to develop a response framework that would establish protocols for delivering emergency services and prevent COVID-19 transmission within the. Furthermore, the task forced developed plans for reopening the SOD for elective dental treatment once the governor and dental board lifted their orders.

By sharing our experience, we would like to emphasize the importance of teamwork, the adoption of clear guidelines and strict preventive measures in dealing with the crisis. We hope that health care facilities facing similar or future sanitary emergencies can use this information to enhance their preparedness to safeguard health care providers and patients.
WVU School of Dentistry Response to COVID-19

On March 16, 2020, the SOD ceased delivery of all elective procedures. Moreover, all in-person lectures, seminars, and conferences were replaced with online platforms. The Urgent Care Clinic (UCC), continued providing urgent care primarily in conjunction with the oral and maxillofacial surgery and endodontic clinics. An occasional case required referral to restorative, prosthodontic, periodontic or orthodontic services. Pediatric cases were typically addressed in the pediatric dental clinic. The TF developed a weekly rotation schedule staffed by SOD faculty permitted to provide care (many had one or more risk factors and were directed to remain at home) and supported initially by students which were eventually replaced by residents from the various specialty programs. In order to determine a patient’s need for urgent or emergency care, the TF applied ADA guidelines (see Table 1) ²⁶.

EVALUATION/SCREENING OF PATIENTS

The TF implemented the following modifications to the school’s usual provision of emergent/urgent services (see Table 2):

Patients contacted the SOD receptionist to schedule an UCC visit. They were scheduled in small groups (maximum of 4) every hour. A separate section of the EHR was set up to record appointments for pediatric and endodontic patients who were seen in their respective clinics directly.

At the time of the call, the receptionist determined a patient’s need for urgent or emergency care by applying the ADA guidelines mentioned above. If there were questions about their need for care, the receptionist would confer with one of the attending faculty. The receptionist additionally completed the COVID-19 screening form with the patient (with the exception of temperature, which was taken when the patient presented for check-in). The patient was then given an appointment or informed that due to a positive response on the questionnaire, a faculty member would be contacting them for further assessment. After consultation with SOD faculty, if it was determined that the patient’s questionnaire responses warranted further evaluation, the patient was asked to see their primary care provider. If cleared by their physician, the patient was given the opportunity to be seen at the SOD.

In order to reduce the time a patient spent within the facility, the patient’s medical history and chief complaint were obtained via a telephone call with a dental hygienist. The EHR was updated for patients of record while first time patients required that a more detailed history be obtained. On this phone call, the DH also confirmed the patient’s appointment. The patient was advised to wear a mask when entering the SOD and that no one should accompany them, unless completely necessary. If a DH was not able to reach the patient, the appointment remained active but not confirmed in the system. These patients had their medical history updated at the time of the appointment. UCC providers reviewed the schedule on a continuing basis to better prepare for upcoming patients.

Patient processing during appointment:

1. Patients were checked in at a reception desk where the staff wear masks, eye protection and gloves
2. Registration information was updated as needed for insurance purposes
3. The COVID-19 screening form was updated and the patient’s temperature taken. If the temperature was > 99° F, faculty were informed and further evaluation made. Consents/policies were signed (general consent, COVID-19 consent, notice of privacy practices, payment policy) and fees collected
4. Patients were directed to a waiting area, which had been modified to provide social distancing, and without magazines or pamphlets
5. The patient was escorted to the clinic and rinsed with either 1% hydrogen peroxide or 0.2% povidone-iodine for 1 minute
6. All documents were reviewed and updated and vital signs recorded
7. Panoramic radiographs were taken for most patients to avoid the gag reflex or cough that may occur with intraoral imaging. Periapical/bitewing films were taken whenever necessary
8. Faculty reviewed all documentation, discussed the CC with the patient, performed a clinical exam, reviewed radiographs, obtained consults when needed, developed a diagnosis and discussed treatment options with the patient
9. Once the patient accepted the treatment approach, they were referred to the appropriate service
10. The pediatric clinic evaluated and managed all emergencies for the pediatric population

807 patients were seen in the UCC between March 16 and May 15, 2020. While most came from within the state, 6.3% came from the bordering states of Pennsylvania (where dental offices were totally closed starting March 24, 2020) and Ohio. 385 patients (48%) were male and 422 (52%) female. 625 patients were medically compromised with 27% of these having two medical conditions and 38% reporting three or more comorbidities. The most commonly reported issues were diabetes, cardiovascular, pulmonary and genitourinary diseases and a history of cancer. A number of patients suffered from obesity and a significant percentage were tobacco users. Patients ranged in age from 18 to 91 years, and 51% were over the age of 40. Presenting clinical conditions requiring immediate attention are listed in Table 3.

Attempts were made to keep all interventions minimally invasive, and avoiding the generation of aerosols when at all possible. The Department of Oral and Maxillofacial Surgery performed a total of 738 extractions.

TREATMENT PROTOCOLS
Oral and Maxillofacial Surgery
The majority of procedures completed in this department were dental extractions of non-restorable teeth, management of pericoronitis, incision and drainage of abscesses of odontogenic origin, and treatment of mandibular fractures. It is important to note that there were occasional known COVID-19 positive patients who contacted the SOD complaining of symptoms consistent with a diagnosis of pericoronitis. These were managed pharmacologically when appropriate.

Restorative Dentistry and Prosthodontics
Treatment included the placement of temporary restorations and recementation of temporary fixed prostheses. Repair of removable prostheses was accomplished during the first two weeks of the lockdown and consisted of adjustments, repair of broken dentures or replacement of dislodged teeth. During the height of the pandemic, these cases were postponed.

Endodontics
Without proper endodontic care, patients are more likely to seek care in urgent care facilities/emergency rooms. After UCC referral to the endodontic clinic, informed consent was obtained and included expected survivability of the treated tooth, as it was uncertain when treatment could be completed.

Treatment modalities relied on well-honed diagnostic skills and ranged from caries excavation to complete root canal therapy. The decision tree was based on what treatment would least likely result in return to the UCC with available time to provide care. Restorative options ranged from long-term interim restorations to completed cores. Short-term temporary materials were not placed. If possible, endodontic procedures were completed and final core restorations placed. This provided the most predictable outcome while reducing the chance of a backlog of patients waiting for elective care. The literature supports the utilization of strict criteria when considering antimicrobial therapy. Antimicrobials are to be considered only after appropriate endodontic therapy and limited to cases with systemic signs and symptoms.^{27, 28}

Infection control guidelines were followed using updates as they became available.
Perhaps the greatest protection afforded to dental HCP was the use of dental dam isolation combined with appropriate disinfectant measures.^{29, 30}

Periodontics
Clinicians practiced in the UCC while also providing emergency care to their own pool of patients. Services included suture removal, replacement of healing abutments, removal of failed implants, sequestrae, and exposed non-resorbable membrane.

Orthodontics
Adjustments of orthodontic wires piercing the oral mucosa, and loose brackets were repaired by clinicians in this discipline.

Pediatric Dentistry
Procedures performed during the urgent/emergent care phase included limited oral evaluations, radiographs, referrals to endodontics or OMS when necessary, extractions under local anesthesia, use of nitrous oxide when necessary, placement of space maintainers, application of silver diamine fluoride, placement of temporary restorations including removal of caries with hand instruments, use of IRM or glass ionomers (GI) and placement of anterior strip crowns with GI.

DISCUSSION
It has been several months since the first COVID-19 case was reported and the pandemic is still prevalent in a number of states. The impact of this pandemic has been tragic and catastrophic, having incurred serious health and economic consequences. Despite large-scale community transmission of coronavirus, demand for emergent dental treatment has been steady. In our school, the demand for emergent treatment decreased by only 10% compared with the same period in 2019. The relatively steady number of urgent care patients between 2019 and 2020 is also attributable to the fact that a number of local private practices were closed, and many patients from these practices looked to WVU for urgent care. Timely and major reorganization of dental care services was challenging, particularly during the initial phase of a pandemic when redistribution of human and material resources had to be expedited.

There are several characteristics in WV that make the state more susceptible to the devastating outcomes of SARS-CoV-2 infection. According to the U.S. Census Bureau (2018) – American Community Survey 1-year estimate, the population of WV was 1,805,832, 54% of whom are over the age of 40.31 The following table (see Table 4) summarizes a 2018 WV Behavioral Risk Factor Surveillance System Report. ³² The only dental school in the state, the WVUSOD provides education and training for future oral health care providers while also serving the oral health needs of the citizens of WV. The University of Pittsburgh School of Dentistry is our closest neighbor, some 80 miles from our location.

As the only open oral health care facility in WV and the surrounding areas during the lockdown, WVUSOD was an important source of urgent care services for a high-risk population. Our faculty, students, and staff played a critical role in this pandemic, detecting patients with initial symptoms, supporting the population even in these dire times, and working in a safe contagion-reduced environment. During this period, none of our personnel developed any signs or symptoms that could be suspicious of COVID-19 infection.

The creation of a SOD COVID-19 task force allowed an efficient and coordinated response to the pandemic threat. In our school, this group was able to bring together a specific set of knowledge and skills to accomplish a critical short-term task. Valuable resources such as previous studies from other countries, dental associations’/institutions’ recommendations, regulatory and advisory bodies as well as expert opinions were all important factors in the decision-making process.
We would like to highlight the significance and importance of incorporating a two-phase triage process, first by phone and then in the clinic, which helped in detecting patients at potential risk of infection by asking each patient twice about their health and potential risk factors. Certainly, pre-triage and triage play an important role in keeping our patients, faculty, staff, and students safe (see Table 5). Moreover, our admissions process reduced the number of patients who were present at one time, and further reduced the amount of time each patient spent in the clinic.
Literature and clinical experience are still limited regarding PPE recommendations for treating patients with confirmed COVID-19 diagnoses for urgent dental procedures. Significant scientific data concerning all aspects of COVID-19 is still being collected. HCP have the duty to stay abreast of the latest developments in order to protect the public and maintain high standards of care and infection control. It is of the utmost importance to establish clear guidelines to prevent and control COVID-19 infection in oral diagnosis and treatment until a vaccine or effective treatment becomes widely available. The TF will continue to develop tools and guidelines to support our community after the COVID-19 closures and practice restrictions are lifted.

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    This submission is included in the JADA+ COVID-19 monograph as a Clinical Observation entry and has not been peer reviewed.
    
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