Part 1: Oral Health and Healthcare during COVID-19: Lessons from India, Kenya and the United States

Oral health services have been severely impacted by the COVID-19 pandemic. As healthcare systems struggle to cope with an increasing number of COVID-19 patients, there has been a decline in the provision of elective and non-emergency oral healthcare at both the public and private levels. This has impacted access to and utilization of dental services, training and education of dentists and dental students, and community-based outreach and programming. In collaboration between Columbia Global Centers | Mumbai and Columbia Global Centers | Nairobi for a two-part series, we discussed lessons learned from India, Kenya and the United States in finding innovative ways to provide in-person and virtual clinical and outreach services in dental healthcare delivery during this pandemic.

Program Moderator:

Kavita P. Ahluwalia – Associate Professor and Program Director, Postdoctoral Program in Dental Public Health, Columbia University College of Dental Medicine (CDM)

Panelists:

Biana Roykh – Associate Professor and Senior Associate Dean for Clinical Affairs, Columbia University College of Dental Medicine (CDM) 
Sharon Perelman – Assistant Professor and Chief Medical Informatics Officer, Columbia University College of Dental Medicine (CDM)  
Regina Mutave James – Professor and Dean, School of Dental Sciences, University of Nairobi, Kenya
G. Rajesh – Professor and Head, Public Health Dentistry, Manipal College of Dental Sciences

Webinar Highlights:

Kavita P. Ahluwalia – Although the mouth is central to eating and nutrition, communication and socialization, health, wellness, and quality of life, the access to and utilization of dental services across the globe is not equitable. (Time frame from minute 02:35-02:50)

Kavita P. Ahluwalia – Public and private systems of care have been asked to provide only emergency and urgent services in part due to concerns associated with the aerosolization associated with dental care and also, in some cases, because vital PPE was redirected to medicine. Dental community education has been lacking. For example, most public health entities have promoted mask-wearing, hand washing, and surface sanitation but there’s been little guidance regarding how to prevent infection via toothbrushes and oral aids, although they are close to the mouth, which we think is the primary mode of infection, and an advice on how to keep the mouth healthy during this time when dental services are severely curtailed has not been forthcoming. (Time frame from minute 02:58-03:51)

Biana Roykh – A very important part of the journey has been to really connect with our workforce and really understand where people are in their experience of the pandemic and their lives. On March 9^th, a lot of clinics closed operations. Our staff were remote, and so we needed to make sure that we can connect with them. So we deployed a number of surveys to all of our workforce to try to understand their attitudes about the pandemic and their willingness to reutn into the workforce once the pandemic starts to subside. (Time frame from minute 06:09-06:49)

Biana Roykh – Additional serving that we did was around our facilities, needs assessment of our facilities. Me coming on board as a new clinical dean, it poses a good opportunity to take a fresh look at everything, COVID-related or not COVID-related. As part of the assessment, of course, we focused on survey of our facilities related to air flow. (Time frame from minute 06:55-07:14)

Biana Roykh – There’s been an infection prevention committee that has been meeting weekly and doing a lot of work in putting together guidelines, updating guidelines, as the guidelines from CDC and local governing bodies were emerging. So that was a big body of work that has been put into place to prepare for a safe return. The second thing that we did was doing a walk-through of all of our faculty practices and our teaching clinics and organizing a restart into three phases, a decluttering phase, facilities and improvements that had to be made, and finally a development of what we call functional workflows with a focus on social distancing wherever possible and into integration of new guidelines and protocols to make sure that we can keep our people and our patients safe. (Time frame from minute 07:50-08:40)

Sharon Perelman – We had been on newly integrated medical and dental electronic health record called EPIC for about five weeks before we had to shut down for COVID. What we did is we looked at the tools that were available in EPIC and came up with a solution that we were going to develop an algorithm that would be a very easy interface for our faculty to use to determine what was the recommended course of treatment for a patient based on all these different guidelines. (Time frame from minute 27:38-28:12)

Sharon Perelman – The algorithm that we developed begins with a screening of the patient’s pain level. That was the common reason that a patient would call. So we would do a pre-screening with the patient by a faculty member to determine what their pain status was like. Based on that, we decided to develop acuity levels how we could rate these patients to determine what was the intervention required at the time based initially on the pain screening. Then following that is the screening based on dental conditions. (Time frame from minute 29:13-29:48)

Sharon Perelman – The output of our algorithm was really to determine a pain of a none, moderate, or severe. Then an acuity level as the interventions that I just mentioned know where to mention urgent recommend comprehensive, non-urgent comprehensive care, or palliative. Come into the clinic and we will screen you in the clinic for your dental emergency or, in some cases, refer the patients directly to the emergency room. (Time frame from minute 33:51-34:18)

Sharon Perelman – Our patients are not only screened by telehealth. They actually come into the clinic. When they come to the clinic, we go through their COVID screening first. Depending upon the output of that COVID screening, if we think there’s a potential that patient was exposed to COVID, then we would room them immediately to take them out of the general clinic population. (Time frame from minute 35:38-36:00)

Regina Mutave James – Immediately after the announcement of the first COVID case, we experienced a very interesting, it wasn’t unique to us, we experienced a very severe shortage of personal protective equipment. We were left with no option but to close all of our clinical services and also have a very basic emergency services that we tried a lot to manage by phone and very minimal coming on site. The basic infection control could not hold anymore. SO we have done a technical retreat and we are still reassessing the situation. We set up COVID response committee at the school, which has covered crowns including the training of staff. (Time frame from minute 39:38-40:34)

Regina Mutave James – The Ministry of Health also issued guidelines in April and I think other also struggled with really separating what is a true emergency according to the professional definition and what patients’ term as emergency situations for them. (Time frame from minute 43:32-43:55)

Regina Mutave James – The ministry guidelines were clear that you could only send those ones to the health facilities within hospitals and the dental school has one such facility that was open for emergencies. We received patients from private practitioners. But the conversation led to a revision of guidelines by the Ministry of Health. Therefore, from around May 2020, there has been a little bit of improvement in the facilities that have prepared themselves and opened for emergencies other than the dental school. (Time frame from minute 45:10-45:47)

Regina Mutave James – Although we have retrained all our staff and students and introduced a telephone triage, we are trying to operate on bookings only. In the long term, it does look like we have to shift our gear from the current treatment, therapeutic-oriented dental practice and really see if we can offer some prevention and promotive services and reduce the numbers of patients that are coming with dental issues. (Time frame from minute 48:22-49:00)

G. Rajesh – We have to look at initial criteria for triaging and screening and subsequent treatment of dental patients. The dental institutions are divided into different zones or the patients visiting the dental institutions are also categorized based on their address as red zone, orange zones, or green zones. If a patient is from containment zone, it is very obvious that no treatment is to be provided for that particular patient. And of course red zones, we are only looking at emergency dental treatments. In orange zones and green zones, we are looking at emergency and urgent treatment procedures only. (Time frame from minute 53:33-54:13)

G. Rajesh – All routine treatments have to be deferred. This is one standing guideline that we are following. And oral cancer screening wherever it is happening as a part of screening programs have to be deferred. (Time frame from minute 54:19-54:30)

G. Rajesh – All treatment procedures should be undertaken first mainly through teleconsultation. The patient has to first call up the dental institution on provided phone numbers. And then there will be a tele-triage, then the patient has to come of course consent has to be taken during COVID times. This is very important for medical legal issues. Even for subsequent contact tracing and other aspects and patient has to visit a dental institution only with pre-fixed appointments. (Time from minute 55:59-56:25)

G. Rajesh – When the patient comes, we have multiple locations. For one location, there are multiple entrances for the patients to enter. So it becomes very tricky in terms of infection control. So we had to block a few of the entrances and have a detailed workflow SOP. Then there was an SOP for triage patient treatment of course was straightforward. We also realized we need to have SOPs for laboratory procedures once you take dental procedures and you send the material for dental laboratories. So there should be appropriate infection control mechanisms which are COVID compliant. (Time frame from minute 57:25-58:01)