Abstract
Purpose: The COVID-19 pandemic has challenged dental professionals to provide appropriate care while using nationally recognized guidelines to minimize disease transmission. The purpose of this study was to investigate the current practices of dental hygienists in Idaho to better understand how their practices have been impacted by COVID-19 in comparison to national guidelines.
Methods: Practicing dental hygienists licensed in Idaho were invited to participate in a 23-item web-based survey. Items included demographics, guidelines used, procedures employed in response to COVID-19, barriers encountered implementing protocols, and vaccination status. Descriptive statistics were used to analyze the data. A Chi-square test was used to test for association between demographics and national guidance used and vaccination status (p=.05).
Results: Of the 1,200 dental hygienists e-mailed, 185 consented to participate for a response rate of 15.4%. Respondents reported that level 3 or higher filtration masks were worn for every patient (72.9%, n=113) as were gloves (95.5%, n=148) and eye protection with side shields (71.6%, n=111). Most respondents indicated that disposable gowns (68.4%, n=106) and washable gowns (39.4%, n=61) were not available. A majority (56.1%, n=87) indicated they had been vaccinated. Respondents who had been employed for >15 years were more likely to have been vaccinated (χ2 = 15.25, df = 1, p = 0.000) and were more likely to ask their patients if they had received the COVID-19 vaccine (χ2 = 7.99, df = 1, p=0.005).
Conclusion: Infection control practices following national guidance were inconsistent among dental hygienists in Idaho. Further research focusing on factors influencing adherence to national guidance for COVID-19 is needed.
Introduction
COVID-19 has significantly impacted the practice of dentistry, requiring changes focused on overcoming the continual challenges due to COVID-19. Dental health care personnel (DHCP) have had access to national guidelines which help outline the most recommended practices to minimize COVID-19 exposure risk since the early days of the pandemic. The Centers for Disease Control and Prevention (CDC) first established interim guidance for dentistry early in 2020, with ongoing updates throughout the pandemic.1 The CDC recommendations focused on general guidance stating the need to prioritize necessary care to minimize risk and included: screening and monitoring of patients and DHCP; physical distancing; source control, and standard as well as transmission based precautions.1 In communities where disease transmission is moderate to high and during aerosol production procedures, the use of a high level of protection respirator was recommended; respirators could be reused due to supply shortages.1 As N95 respirators became more readily available, the CDC recommended the single use of N95 respirators for aerosol producing procedures.2 In July of 2021, the CDC’s guidance regarding aerosol producing procedures was updated, indicating that these procedures should continue to be avoided in patients suspected of COVID-19.3
Professional organizations such as Organization for Safety, Asepsis and Prevention (OSAP), the American Dental Hygienists’ Association (ADHA), and American Dental Association (ADA) also constructed more detailed, functional guidelines for DHCPs to incorporate practices for minimizing COVID-19 risks while regulatory bodies such as the Occupational Safety and Health Administration (OSHA), and the various state boards of dentistry issued statutes related to practicing during the pandemic.4-7 The ADHA offered specific guidelines for each of the sections of the CDC interim guidelines and also included guidance on key important areas: High-Volume Evacuator (HVE) and dental assistant utilization whenever possible; and aerosol producing procedures.7 The OSAP created a substantial document and toolkit that summarized all of the professional organization’s major recommendations for managing COVID-19 in healthcare practice settings.4
A national study conducted by the ADA Health Policy Institute and the ADHA examined the practice tendencies of a sample population of dental hygienists throughout the United States (US) and Puerto Rico (n=4,776) from September 29 and October 8, 2020.8 Results from this study showed a slight decrease in employment (7.9%, n=205) with the most commonly cited reasons for voluntary departure from clinical practice were issues with workplace safety/standards (12.7%, n=26) and discomfort working until the pandemic was under control (48.3%, n=100).8 Participants were asked regarding their knowledge and level of concern regarding personal protective equipment (PPE) with the majority of participants stating that they had >14 days’ worth of PPE.8 A key discussion point identified COVID-19 vaccination availability as a possible reason for dental hygienists to rejoin the workforce. At the time of the original study, nothing had been reported in the literature addressing the relationship between vaccinations and dental hygienists in the workforce.8
According to the ADA Health Policy Institute, 60.9% of the dentist respondents in the US reported being open and running their practice as customary, and >80% report having eight to >14 days’ worth of the CDC recommended PPE.9 The Health Policy Institute reported 58.6% of the dental hygienists surveyed were working full-time while 32.3% are working part-time; >77% of reported having eight to >14 days’ worth of the CDC recommended PPE.10
With the development of the three types of COVID-19 vaccines,11 and due to the increasing availability of the vaccines, the CDC officially recommended all healthcare workers to be COVID-19 vaccinated as of May 2021.12 At the time of this study period, 49.8% of the US population had been fully vaccinated13 and nationally 52.2% of dental hygienists had been fully vaccinated,14 demonstrating dental hygienists have kept pace with the vaccination rate across the country.
While some workplace safety issues, such as availability of vaccinations and PPE, have been addressed, it is unknown how these issues have influenced the practices of dental hygienists in relation to COVID-19. It is also not known whether years of experience or if full versus part-time employment status impacts dental hygiene practice or COVID-19 vaccination status. Lastly, it is unknown whether COVID-19 vaccination status is associated with inquiring whether patients have received the COVID-19 vaccine. Previous research has been conducted on a national population; little is known about practices in individual states. Therefore, the purpose of this study was to investigate the current practices of dental hygienists in the state of Idaho to better understand how their practices have been impacted by COVID-19.
Methods
A descriptive research design was used to study COVID-19 practices of dental hygienists in Idaho. A web-based survey was administered (Qualtrics, Provo, UT, USA) from April to June 2021. The research protocol and survey were approved by the Idaho State University Human Subjects Committee (IRB-#FY2021-212). Although there were 2,073 dental hygienists licensed in the state of Idaho, there was an available contact list of 1,200 dental hygienists at the time of this study. The dental hygienists in this contact list (n=1,200) received an invitation to participate in the survey; two reminder emails were sent. Individuals were eligible to participate if they were licensed, currently practicing and were at least 18 years of age.
Potential participants read and signed an electronic informed consent before beginning the survey. The 23-item survey was constructed using items similar to a national survey of US dental hygienists conducted previously.8,15 The modified survey was reviewed by a group of dental hygiene educators and clinicians for content validity, and by a statistician who evaluated the instrument in relation to the purpose, research questions, content, and to determine the statistical analysis plan. Minor modifications were made based on feedback. Demographic survey questions included age, sex, primary practice setting, employment status, and years of experience as a dental hygienist. Participants were asked to identify which guidelines were used to determine appropriate practices to address COVID-19 in their dental practice setting and which procedures they were employing in response to COVID-19 for both patients and for themselves.
In addition, participants were asked what barriers they encountered over the past month related to implementing COVID-19 national guidelines into their dental hygiene practices, and what things would they like to see available to help them use these guidelines in their daily practice. Finally, respondents were asked if they had been vaccinated against COVID-19, if they were a COVID-19 vaccine administrator or were planning to become one, and whether they routinely ask their patients if they have received the COVID-19 vaccine.
Frequencies and percentages were calculated for all survey items. For categorical variables, differences were tested using χ2 tests with statistical significance set at a minimum of 0.05. Due to the survey design skip patterns (respondents were able to skip any question or stop answering the survey at any time) not all respondents answered all questions; the percent missing ranged from 0 to 9.0% per question.
Results
Of the 1,200 dental hygienists e-mailed, 185 consented to participate for a response rate of 15.42%. Most (83.8%, n=155) were licensed dental hygienists practicing in Idaho, while the remainder (16.2%, n=30) were practicing outside of the state. For respondents not currently practicing in Idaho the reasons for being out of state included: voluntarily left the state (33.3%, n=10), retired (20.0%, n=6), working in another state (20.0%, n=6), working in a non-clinical position (13.2%, n=4), COVID-19 (3.3%, n=1), laid off/furloughed (3.3%, n=1), permanently let go from position (3.3%, n=1) and missing response (3.3%, n=1). The results that follow pertain only to those respondents practicing within the state of Idaho.
Respondents were predominantly female (99.4%, n=154); one respondent was male (0.6%, n=1). Age and years of practice were closely distributed. The majority (52.3%, n=81) worked full-time (>31 hours per week) while nearly half (47.1%, n=73) worked on a part-time basis (<31 hours per week). Most (78.7%, n=122) worked in a clinical private practice setting. Demographics are shown in Table I
Sample demographics* (n=155)
Respondents were asked to indicate what guidelines they consulted to determine appropriate protocols to address COVID-19 in their practice settings. The guidelines chosen most often were the CDC (89.0%, n=138), ADA (87.1%, n=135), and OSHA (78.7%, n=122). A Chi-square test of significance was used to determine if there was a statistical significance based on response to this item by employment status (full-time versus part-time) and years of experience. The Bonferroni adjusted criterion for statistical significance was indicated to adjust for a type 1 error, accounting for the seven tests evaluated; the p value was set at 0.007. None of the χ2 tests were statistically significant for either employment status or years of experience (data not shown).
Protocols utilized for patients and dental team members in response to COVID-19 were surveyed. Most frequent protocols being used for patients included screening questions at the appointment (75.5%, n=117), and face coverings worn in all areas of the practice setting (83.2%, n=129). Most respondents reported they rarely followed-up with patients after appointments to check on symptoms for COVID-19 (89.0%, n=138) and most did not telescreen patients prior to appointments (52.9%, n=82), have patients wait in the car prior to appointments (62.6%, n=97), or ask patients to use hand sanitizer prior to beginning an appointment (59.4%, n=92) (Table II). However, respondents were more likely to routinely implement safety practices for dental team members (Table III). Exceptions included regular temperature checks (52.9%, n=82) and maintaining physical distancing (51.6%, n=80) with most reporting that they were more likely to defer performing these precautionary procedures.
Patient management practices used in response to COVID-19 (n=155)
Procedures implemented routinely for patient care in response to COVID-19 showed that most participants were donning and doffing PPE between patients (59.4%, n=89) and hand scaling (80.6%, n=125). However, respondents also reported that they were not avoiding ultrasonic scaling (66.5%, n=103) or coronal polishing (88.4%, n=137), and if ultrasonic scaling was deemed essential, they did not use four-handed dentistry and two HVE systems (73.5%, n=114) (Table IV).
Practices routinely implemented among dental team members in response to COVID-19 (n=155)
Patient care procedures routinely implemented in response to COVID-19 (n=155)
When asked what PPE was currently being used in practice, respondents reported that level 3 or higher filtration masks were worn for every patient (72.9%, n=113) as were gloves (95.5%, n=148) and eye protection with side shields (71.6%, n=111). However, respondents indicated that disposable gowns (68.4%, n=106) and washable gowns (39.4%, n=61) were not available. Most (63.2%, n=98) reported that a dental team member had been assigned as an infection control officer for the practice. Types of PPE used are shown in Table V.
Current PPE used in practice (n=155)
Respondents were asked to describe barriers encountered over the last month related to implementing COVID-19 national guidance into dental hygiene practice. Options for responses included: lack of PPE, lack of manager/employer support, lack of time, lack of knowledge of national guidelines, national guidelines are hard to understand, lack of dental team members, patient demands, employer demands. The only barrier that received a majority response as a concern was lack of PPE (49.7%, n=77).
Regarding vaccination status, over half of the respondents (56.1%, n=87) indicated they had been vaccinated for COVID-19 while 40.6% (n=63) were not vaccinated. For those who were not vaccinated, reasons reported included: already had COVID-19 (4.5%, n=7), did not feel vaccines were safe (6.5%, n=10), waiting to see the side effects (3.2%, n=5), do not trust vaccines (0.6%, n=1), have other medical conditions and concerns about how the vaccine will affect health (1.3%, n=2), pregnant (2.6%, n=4), and not enough long-term research information available (8.4%, n=13). Two individuals (1.3%) indicated they were a COVID-19 vaccine administrator and six (3.9%) reported they are planning to become one. Lastly, only 31.0% (n=48) respondents indicated routinely asking their patients if they have received the COVID-19 vaccine.
Chi-square test of significance was performed to determine if there was a difference between employment status and vaccination status. No significant difference based on employment status was identified (χ2=.005, df=1, p=0.95). How-ever, there was a statistically significant difference in vaccine status between respondents who had been employed for greater than 15 years versus those who had been employed for less than 15 years. Respondents who had been employed for more than 15 years were likely to have been vaccinated (χ2=15.25, df=1, p=0.000). Further, there was a statistically significant difference for respondents who were vaccinated in terms of asking whether their patients had received the COVID-19 vaccine. More respondents who were vaccinated asked their patients whether they had received the COVID-19 vaccine (χ2=7.99, df=1, p=0.005).
Discussion
COVID-19 has significantly impacted the practice of dental hygiene. Adaptations in clinical practice settings were essential to ensure the safety of the public and DHCPs. The practice trends noted in the national survey indicated that not all national guidance recommendations were being followed.10 Therefore, this study was undertaken to provide a snapshot of the COVID-19 practices in one state to compare the findings to the national sample.
Employment practices of dental hygienists both nationally and statewide appeared comparable. In the national survey, 90.9% the respondents were employed either full- or part-time, while 99.4% of the respondents in Idaho were employed during the same time period.10 Most of the respondents worked in clinical practice settings both nationally and in Idaho. However, there were differences found regarding the availability of PPE. While masks, face shields, and gloves appeared to be readily available as reported in the national survey, gowns and face shields with side extensions were not nearly as available in Idaho. This lack of PPE was noted as a major concern by the Idaho respondents, contradicting the national findings.
Although there are multiple national guidance resources available to assist DHCPs manage COVID-19 risks, and most respondents reported using the CDC interim guidance, ADA, and OSHA documents, findings from this study revealed that many of the guidelines were not being followed. For example, there was a tendency to avoid screening protocols for both patients and DHCPs and many respondents indicated they performed aerosol generating procedures without additional HVE. It is difficult to determine what influencing factors impacted DHCPs decision making related to national guidance. Concerns expressed regarding the availability of PPE did not correlate with the extent of the avoidance of other practices such as patient screening and aerosol generating procedures.
Another significant factor which may be contributing to guideline variations may be the vaccination rate among the respondents and the public. During the study as of July 28, 2021, the US rate of fully vaccinated individuals was 49.8%,13 while the rate for those living in Idaho was 37.3%.16 In comparison, 52.2% of dental hygienists in the US were fully vaccinated14 whereas 56.1% of the Idaho survey respondents were fully vaccinated. As more individuals become vaccinated, respondents may have had a false sense of security making them feel better protected in clinical practice and less inclined to follow national guidelines. The current study was conducted prior to any CDC guideline relaxation; therefore, it is important to recognize the risks and threat of transmission had not diminished.
Termination of COVID-19 risk mitigation protocols among DHCPs is concerning considering the current infection rates are elevating due to new variants of COVID-19.17 As of August 2021 there were four known variants of COVID-19, Alpha, Beta, Gamma, and Delta and five emerging variants Eta, Iota, Kappa, Lambda, and Mu.18 The greatest concern related to the variants is the high-transmission rate which is gaining momentum even in countries with high vaccination rates.19 Therefore, crucial transmission components must be maintained including social distancing, facial coverings, vaccines, and other proven public health measures.19,20 One example of a public health measure to mitigate risk, in the state of California DHCP were required to be COVID-19 vaccinated by August 23, 2021.21 Consequences of non-compliance with the California vaccination requirement are weekly COVID-19 testing and mandated surgical masks in place of other face coverings.21 The CDC’s response to the rising infection rates due to the variants has been indoor, public mask recommendations for fully vaccinated people.22 Preliminary findings from a study conducted in Chile concluded the Lambda variant may be COVID-19 immunity evasive, underscoring the continuously evolving nature of the virus.23 Vaccination status should not solely guide DHCPs practices, and national guidelines should continue to be followed.
A notable finding from this study was that more respondents who were vaccinated also asked their patients if they had received the COVID-19 vaccine. It is recommended that the immunization history be taken, and patients be assessed for additional vaccines as part of a thorough medical history review.24,25 Comprehensive immunization documentation can be accomplished through patient vaccination questioning. With the availability of dentists and dental hygienists as vaccine administrators, the potential exists for in-office immunization for COVID-19 and other essential vaccines.24,25
There are limitations to this study. The low response rate limits its generalizability. It may be that the response rate reflects COVID-19 fatigue or a lack of desire in addressing topics related to this subject matter. In addition, these results were based on self-reported data, which may be associated with recall or social desirability bias. Future research should examine what factors influence adherence to national guidelines including new variants of COVID-19, vaccination status, and vaccine administration in dental practice settings. In addition, factors affecting adherence should be explored from a qualitative perspective to provide greater understanding of decision making among practitioners.
Conclusion
Infection control practices following national guidance were inconsistent among dental hygienists in Idaho. Lack of PPE was identified as a primary among the participants. Dental hygienists with more years of employment were more likely to be vaccinated and determine the vaccination status of their patients. Future research should focus on factors influencing adherence to national guidance.
Footnotes
This manuscript supports the NDHRA priority area Professional development; Occupational health (determination and assessment of risks).
- Received August 12, 2021.
- Accepted December 9, 2021.
- Copyright © 2022 The American Dental Hygienists’ Association
