Abstract
Purpose The relative newness of Post-COVID Conditions (PCC) has revealed a void in assessment protocols and treatment guidelines for dental settings. Providing oral health care practitioners with an assessment and treatment protocol could facilitate the delivery of comprehensive oral health care. The purpose of this study was to test a protocol for assessing and treating patients with PCC in dental practice settings.
Methods A qualitative exploratory research design was used to conduct the study. A PCC assessment and treatment protocol (ATP) was developed and was used by dental hygienists in clinical practice in California for a period of 6 weeks. Following the use of the PCC ATP practitioners were invited to participate in individual interviews. Online individual interviews were comprised of 20 dental hygienists recruited via purposive sampling. Participant anonymity was preserved using pseudonyms. A qualitative analysis software program was used to identify codes and themes. Investigator triangulation, member checks, and saturation were used to validate responses.
Results Fifty-six participants completed the six-week PCC ATP and twenty participants took part in the interview session. Four themes were identified: awareness, accessibility, resources, and complications. Within the accessibility theme, subthemes of ease of use and guidance emerged. The complications theme yielded three subthemes: time, clinician hesitation, and patient lack of cooperation.
Conclusion This study demonstrated that a PCC ATP created awareness of the varied symptoms of PCC and is a useful resource for clinical practitioners. Providing dental hygienists with a treatment protocol supports efforts to provide person-centered evidence-based care.
INTRODUCTION
First identified in 2019 in Wuhan, China, severe acute respiratory syndrome coronavirus 2 (SARS-Co-V-2) emerged as the coronavirus strain responsible for the coronavirus disease (COVID-19) pandemic.1 Although the pandemic has ended, the disease persists. The World Health Organization reports that as of December 2023, there have been over 770 million confirmed cases of COVID-19 and 6.9 million deaths worldwide, while the United States has experienced over 109 million cases of COVID-19 and over 1.1 million deaths.2 The challenges of the COVID-19 pandemic have been further complicated by prolonged health consequences experienced after resolution of the acute phase of infection with SARS-CoV-2. The Centers for Disease Control and Prevention (CDC) uses the term Post-COVID Conditions (PCC) or Long COVID to describe the variety of physical and mental health symptoms which persist four or more weeks after infection with SARS-CoV-2.3 Some of the symptoms associated with PCC include fatigue, malaise, cough, dyspnea, tachycardia, chest pain, brain fog, headache, peripheral neuropathy, depression, anxiety, post-traumatic stress disorder (PTSD), muscle or joint pain, abdominal pain, nausea, diarrhea, loss of taste/smell, tinnitus, fever, and rashes.4-11
A person previously infected with SARS-CoV-2, regardless whether the disease is mild or severe, can develop PCC.4 Certain individuals may be at higher risk for developing PCC, including those who experienced more severe COVID-19 illness, those who had existing health conditions (prior to their COVID-19 diagnosis), unvaccinated individuals, and those who developed multisystem inflammatory syndrome (MIS) during or after COVID-19 infection.6,7,9-13 Multi-organ effects or autoimmune conditions can result in diabetes, heart conditions, or neurological conditions.12,14 Moreover, individuals suffering from severe illness or hospitalization may also develop new health problems. Post-intensive care syndrome (PICS), although not unique to COVID-19 hospitalizations, can result in weakness, brain fog, and symptoms of PTSD.4 Survivors of COVID-19 who were hospitalized or placed in intensive care are at higher risk of developing PTSD.12,15 The myriad of physical and mental health complications experienced by individuals as a result of COVID-19 pose significant considerations when encountered by oral health care providers in the dental setting.
Another challenge associated with PCC arises when an individual who exhibits the symptoms of PCC but does not have conclusive test results.4 The difficulty in diagnosing the cause of the symptoms can lead to a delay in the patient receiving proper care or treatment.4 The wide variety of symptoms may also be associated with other health problems resulting in difficulty recognizing PCC.16-17 Currently, a diagnosis of PCC arises when a health care provider confirms a previous infection with SARS-CoV-2 along with an evaluation of the patient’s current health for symptoms related to PCC.4 Some individuals experience debilitating effects, while others report mild symptoms.1 Furthermore, some people may not associate their current symptoms with COVID-19.4,18
The relative newness of PCC has revealed limited guidance for oral health professionals in the form of assessment protocols and treatment guidelines. France and Glick16 compiled a table outlining signs and symptoms of PCC, routine medications, oral health interventions, and treatment modifications for dental professionals to use when providing care to patients with PCC. In addition, comprehensive clinical practice guidelines for physicians continue to be published by The American Academy of Physical Medicine and Rehabilitation (AAPM&R) to support the needs of the millions of patients affected by PCC.19 The AAPM&R offers medical guidance for some of the symptoms of PCC including fatigue, neurological symptoms, cardiovascular complications, cognitive symptoms, autonomic dysfunction, and breathing discomfort.20-25 In addition, the AAPM&R provides links to current research and guidance tables.19
The dental hygiene process of care as outlined by the American Dental Hygienists’ Association (ADHA), provides a framework to guide the practice of the dental hygienist in the provision of safe and effective patient care.26 The ADHA supports “comprehensive risk-based assessment of the patient’s needs prior to and throughout the delivery of oral health services.”27 Prior to treatment, a dental hygienist will conduct a health history assessment which includes demographic information, vital signs, physical characteristics, social history, medical history, and pharmacologic history.26 The evaluation of vital signs and the medical history interview are opportunities to identify contraindications or limitations to treatment in the clinical setting. Reviewing pharmacologic history similarly offers insight to recent changes in health. During the patient assessment phase, dental hygienists can identify patients presenting with PCC and make referrals to primary care providers and specialists as needed.
Given the limited availability of resources addressing oral health clinical practice guidelines for managing patients with PCC, the purpose of this investigation was to test an original protocol designed to provide guidance to dental hygienists in the assessment and treatment of patients presenting with PCC in the dental setting. The following research questions guided the conduct of this study:
In what ways is the assessment protocol for treating patients with PCC appropriate for a dental practice setting?
In what ways is the treatment protocol for treating patients with PCC appropriate for a dental practice setting?
What are the barriers to using the assessment protocol?
What are the barriers to using the treatment protocol?
METHODS
A qualitative exploratory research design was selected to evaluate the usefulness of an assessment and treatment protocol (ATP) for Post-COVID Conditions (PCC) and to identify any barriers to its use. The Idaho State University Institutional Review Board approved the study (IRB: FY2023-106). The COREQ Checklist was utilized in formulating and evaluating the study design.28
A purposive sample of registered dental hygienists engaged in clinical practice in the state of California was invited to participate in the study. Recruitment for the study occurred through emails sent by the California Dental Hygienists’ Association and individual dental hygiene association components throughout the state. The support of the California dental hygiene professional associations, the large number of registered dental hygienists in California, and the high rate of COVID-19, set good prospects for a sample population of study participants. Inclusion criteria for participation were registered dental hygienists in California who were engaged in clinical patient care for a minimum of two days per week. Participants were invited to complete a screening survey to determine eligibility for the study.
An original PCC ATP was developed based on the literature related to the assessment and management of PCC and other systemic health conditions.16,29-38 A cohort of five dental hygiene educators and clinicians reviewed the PCC ATP to establish content validity and usability. Comments provided were positive and no changes were recommended to improve the protocols.
A six-week time frame was established to allow participants sufficient time to test the PCC ATP in their dental practice setting (Tables I and II). Participants were then invited to participate in an individual interview following the six-week time frame. Confidentiality and anonymity were preserved using pseudonyms within the virtual video conferencing platform (Zoom; San Jose, CA, USA).
Post-COVID Conditions Assessment Protocol
The interview guide (Table III) was designed to obtain feedback regarding the participants’ experience with the use of the ATP. A semi-structured interview technique was used that included five elements: an opening question, introductory questions, transition questions, key questions, and an ending question asking participants if there was anything they would like the researchers to know about this topic.39 The interview guide was validated by two experts in qualitative research.
Interview Guide
The Principal Investigator (PI) conducted each interview in the presence of one or both coinvestigators, and followed the interview protocol to ensure no biases were introduced to enhance methodological rigor. Each individual interview lasted approximately thirty minutes. The sessions and closed caption transcripts were recorded via the video conferencing platform and saved to an encrypted password protected account. The PI evaluated each transcript to make sure the key concepts were represented. Access to the recordings was limited to the PI and the PI verified each transcript for accuracy. Each participant also reviewed their responses in the transcripts to check for accuracy and the participants were allowed to restate main ideas if needed to establish non-bias.40 Interviews were conducted until saturation was reached with twenty participants, indicating that no new information was provided during further data collection.
The qualitative responses were coded and grouped into parent and child codes related to the participants’ feedback using an online qualitative research analytic platform (Dedoose; Los Angeles, CA, USA).41 The co-investigators systematically reviewed the codes individually and collectively using the classic analysis strategy to identify themes and subthemes.39 Validity was established by pilot testing the interview, investigator triangulation, saturation, and member checks to ensure validity and reliability and that the researchers’ interpretation of the data was accurate.39
RESULTS
Eighty-nine participants completed the screening questionnaire. Fifty-six participants qualified for the study and completed the six-week PCC ATP protocol. Of those individuals, twenty participants participated in the interview sessions. The majority of the respondents were female (95%, n=19), one participant was male (5%, n=1). Participants’ years of practice ranged from 1 to 50 years with an average of 16 years and a median of 18 years. Quotes from the participants were condensed into seven parent codes and 33 child codes. Four themes were identified: Awareness, Accessibility, Resources, and Complications.
Awareness
Participants were asked about their experience in using the PCC ATP. The responses included having a better understanding of PCC and awareness of associated conditions that are related to PCC. Runner Girl stated, “It has made me more mindful about associating different signs and symptoms potentially caused by COVID. Before, I might have thought it was due to some other condition”. Marie added,
“I am more aware when I am asking health history questions. We have not had anything related to post COVID on our medical history update for the last two months that I have been doing it [participating in the study]. It has been eye opening that patients are checking “yes” to some of the symptoms that I had not [asked] in the past.”
Participants also noted the ATP facilitated open communication with patients. Flossy Posse expressed, “I think that the questions evoked good conversations. I would find out from people who knew people who had Long COVID symptoms and I would give them the information that you gave to all of us.” However, Kay noticed that there was sometimes a lack of awareness with patients about PCC and stated, “Patients were kind of wondering why we’re still going into details about COVID, because they feel like that is behind them”.
Accessibility
Participants reported the PPC ATP was very thorough and allowed them to show concern for their patients. Patients also appreciated that questions focused on mental and physical health and not just oral health. Most notably, there were two subthemes that emerged, Ease of Use and Guidance.
Ease of Use
Most participants described the protocols as quick and simple to follow. SY expressed, “I thought the assessment protocol was clear and very easy to navigate. The questions are laid out very clearly and the questions were simple. It was a very easy thing to implement while I had my patient in front of me”. Other participants incorporated the protocols into the health history as evidenced by Flossy Posse who stated, “It wasn’t part of my medical history review and now it is. Mary Jo expressed,
“I would say that the treatment protocol was very helpful. It was thorough which I liked, and it was easy to follow. I liked how it was in a chart form and you could easily look up if that patient is having that symptom. Just follow the column to see how you could treat them or what referral to give, or clinical applications they might be. It was clear and easy to read, and then a nice chair side tool to quickly reference.”
Guidance
Helping clinicians understand the complexities of PCC and adapting to new conditions as they arise provided opportunities to use the PCC ATP as a framework for patient care. Irish Ufloss stated,
“I really like this treatment protocol because I feel like we’ve kind of been navigating this completely blind, not really having something to guide us with, how to talk to our patients about COVID, what we should be looking for and how we can change the appointment to really help them. It made me a better clinician. I felt like I was more knowledgeable about it.”
Mary Jo noted,
“It really helped me identify modifications and where to direct patients when they are having issues. As a new hygienist, this was a life saver for me and it just made me feel a lot more prepared and confident, using this chairside with the patients.”
Resources
Participants recognized the value of the PCC ATP as subject matter information that had multiple applications. For example, Carol reported,
“I’m going to be keeping these protocols handy and will continue to use them for my patients. It opened my eyes to the not so obvious Long COVID symptoms. I can continue to help my patients and the people in my life, my own family. I realized that COVID has really affected myself and my child in ways that I didn’t really connect the dots before. Now I realize that maybe we are having some Long COVID symptoms or some Post-COVID complications. Now I know I have a resource to help me. It’s going to help us not only in our practice but in our personal lives as well.”
Mary Jo noted that the protocols would be important as chairside tools.
“They were great tools, and I would personally use them. I could laminate them and keep them chairside if I come across a patient with PCC. You can easily pull it out during the appointment, and then make sure you’re getting the patient the correct and best advice. Both the assessment and the treatment protocol would be great to have chairside; they’re very helpful and resourceful references.”
Finally, Irish Ufloss indicated the value of addressing mental health conditions as part of the PCC ATP.
“I had a patient who was hospitalized for COVID in December 2021. He was a 43-year-old, male, healthy, no medications. He was so sick he had to be in the hospital for 3 days and he’s the only patient who said that he had anxiety and depression. I really like that you had that in the treatment protocol, because I never would have thought to ask about mental health when it comes to anxiety and depression. He wasn’t taking any medication for anxiety or depression. He was choosing to handle it on his own. The one thing that he said that broke my heart was “when I entered the hospital, I had to leave my wife and 2 young boys, I got scared and thought, what if this is the last time that I’ll ever see them.” It was so bad that he thought he might die. He’s young to have these thoughts. It affected his mental health, thinking that he could have died from COVID.”
Complications
Participants were asked to describe barriers they encountered using the PCC ATP. Although half of the interviewees indicated they did not experience any obstacles using either the assessment or treatment protocol, and others reported complications. Three subthemes emerged including Time, Clinician Hesitation, and Patient Lack of Cooperation.
Time
Participants indicated that time is a factor when being asked to add another element to an already crowded dental hygiene appointment. As Flower declared,
“I feel like an hour is never enough. I am always running behind. It’s not enough to do blood pressure. It’s just a lot. Having frequent breaks sometimes is tough. I’ll talk to a patient and say “let’s tough it through” or having to hand scale more. It’s a barrier regarding treatment protocol.”
Danielle’s comments concurred with Flower as she described,
“Lack of time, really. I want more time sometimes because I feel like it’s a lot of the medical review. Typically, in a normal dental hygiene appointment I don’t have a lot of time for that. I felt like I wanted to spend more time discussing that with the patient than just doing their general hygiene services. It felt more important. That’s my biggest barrier.”
Clinician Hesitation
Some participants appeared to have concerns about aspects of their practice either in relation to scope of practice or the manner in which they provided care. Runner Girl, expressed, “When referring them to their physician, I couldn’t really follow up and say, ‘did you go see them?’ I couldn’t make the appointment for them. It was out of my hands. Irish Ufloss stated,
“I didn’t want to make the patient feel like I’m being too invasive. Just because I am newer to them and they were rarely being asked about their medical history to suddenly being asked a little bit more. That was my barrier. Trying to guide it and ease it in and not feel like I’m trying to step over any boundary.”
Flower also reported reluctance to provide referrals and reported,
“I think for me the one thing that I didn’t utilize with the treatment protocol is the referral column. I think my lack of confidence in being able to have that conversation with patients about referrals. I say, “oh, you should probably go” instead of “you should go.”
Patient Lack of Cooperation
Participants reported there were some patients who had strong feelings about COVID-19 or were reluctant to answer health history questions that pertained to COVID-19 disease or PCC. As Andi indicated,
“Early on, I could tell who was very anti-COVID, or anti-vaccine, or who doesn’t believe in what’s going on, because when you ask if you can ask them these questions, they’d flip out. I did have a couple of patients who don’t believe that any of this actually occurred. That was very interesting to come up against that because I didn’t expect it.”
Carol had a similar experience stating,
“I work in South Orange County and a lot of my patients think that COVID wasn’t a thing and they’re a little resistant to talk about it or if they had it, they get offended if you ask them about it, or they blow it off like it was no big deal. I had to beat around the bush almost to determine if they had any symptoms or issues. If they mentioned anything about symptoms, I would ask if they had COVID. They would answer “no, of course I didn’t have COVID.” I’m convinced a lot of my patients weren’t even testing for it.”
Additional supplemental quotes related to the themes and subthemes are shown in Table IV.
Supporting Quotes Related to Themes and Subthemes
DISCUSSION
The outcomes of this study support the usefulness of an original PCC ATP for utilization in clinical practice settings. Qualitative responses from participants revealed themes associated with both facilitators and barriers to implementation. This data is beneficial in the further development of the protocol as a living document. Information from this research study can be used to develop clinical practice guidelines (CPGs) to aid in the assessment and treatment of patients with PCC.
The American Dental Association (ADA) describes CPGs as “the strongest resources to aid dental professionals in clinical decision making.”42 Facilitators as well as barriers to CPGs must be evaluated to ensure adoption. In this study, there were four themes (Awareness, Accessibility, Resources, and Complications) which emerged from the research participant interviews that relate to the framework of CPGs.
Awareness was a recurring topic associated with the use of the PCC ATP. In a systematic meta review of facilitators and barriers of CPG, Correa et al. found that leadership and administrative support were strong facilitators.43 When there is an expectation of application of a clinical standard, clinicians are more likely to comply and have awareness of the expectation. De Velminck et al. explored barriers and facilitators for patient interventions in a systematic review and found that accumulated skills to respond to a patient’s needs were a strong facilitator.44 Conversely, research conducted by Guncu et al. found a lack of awareness led to clinician hesitation in implementing CPGs.45
The second theme of Accessibility was supported by subthemes of ease of use and guidance. Participant responses were favorable in describing the ease of use of the PCC ATP as well as showing regard for its value as a clinical guide. Research from Lau et al. established the presence of evidence-based practice and patient-centered care as strong facilitators of implementation of CPGs.46
The value of a protocol or CPG can be diminished if the barriers to implementation are not addressed. The barriers in this research study were related to the theme of Complications with subthemes of time, clinician hesitation, and patient lack of cooperation. Overwhelmingly, time was named as a barrier to implementing the PCC ATP. This finding echoes what has been previously identified in the literature regarding the implementation of CPGs. Stewart et al. conducted a scoping review of “theories used to investigate clinician adherence to clinical practice guidelines’’ which revealed busy schedules as a barrier.47 Likewise, Lau et al. in a systematic review of reviews noted clinician perception of time as a barrier.46 Additionally, in a systematic metareview of the literature Correa et al. noted lack of time as a relevant barrier to the implementation of CPGs.43 Further, Spolarich explored the challenges in applying evidence-based research to clinical practice and also noted lack of time as a barrier.48
Another barrier identified in implementing the PCC ATP was evidenced by the subtheme of clinician hesitation. Participants mentioned hesitation regarding initiating referrals, explaining that it may be out of the scope of their practice or a sense of uncertainty regarding incorporating the ATP within the dental setting. Spolarich43 and Correa et al.48 also revealed lack of knowledge on the part of the clinician as a barrier. Additionally, Spolarich43 and Lau et al.48 noted confusion about clinician roles and responsibilities as barriers to implementing CPGs, while Lau et al. also cited additional workload as a barrier.48
The subtheme of patient lack of cooperation emerged as a barrier to implementation of the PCC ATP. Participants shared experiences of patients’ attitudes and beliefs regarding COVID-19 and PCC as no longer being a relevant concern. This relates to the finding of Correa et al. regarding patients’ negative attitudes towards implementation of CPGs, a lack of knowledge, and sociocultural beliefs.43
Findings from this study suggest that providing clinicians with evidence-based guidelines for assessing and treating patients with PCC in the dental setting is a useful resource. Providing training to oral health care providers to clarify roles and responsibilities, scope of practice, timesaving or efficiency strategies can address the barriers noted in the results from this study as well as the literature. Modifying the PCC ATP to be accessible as a chairside resource may also increase compliance.
There were limitations to this study. The primary limitation is related to the purposive sampling which limits generalizability of the findings. However, in qualitative research, interviews are not intended to generalize but rather to delve deeper into a topic.39 Qualitative research methods can provide insight into perceptions and opinions which may not be revealed in a quantitative research design. There is also the potential for bias when the PI acts as the moderator and is involved in the data collection. However, strategies such as pilot-testing, member checks, and the presence of co-investigators were utilized to control bias.
Suggestions for further research include implementing the PCC ATP guidelines among dental hygiene education programs to prepare students to provide appropriate care for patients with PCC. In addition, it is recommended the ADHA use the PCC ATP as a framework to develop consensus guidelines for dental hygiene practice.
CONCLUSION
Four themes emerged regarding the use of a Post-COVID Conditions (PCC) assessment and treatment protocols from this qualitative study of dental hygienists engaged in private practice in the state of California. Findings revealed that participants found the protocols created awareness of the varied symptoms of PCC and that the protocols were both accessible regarding ease of use and helpful as a guide or resource. Complications in the use of the protocols were related to time, clinician hesitation, and patient lack of cooperation. Providing dental hygienists with these resources supports efforts to provide person-centered evidenced-based care. The PCC assessment and treatment protocols may provide a useful framework to develop future clinical practice guidelines for dental hygiene practice.
DISCLOSURES
The authors have no outside financial support to declare or conflicts of interest to report.
ACKNOWLEDGEMENTS
The authors wish to acknowledge the individuals who participated in the study and shared their insights regarding use of the protocols.
Footnotes
NDHRA priority area, Client level (Oral health care) new therapies and prevention modalities.
- Received December 15, 2023.
- Accepted February 12, 2024.
- Copyright © 2024 The American Dental Hygienists’ Association
