If you have had a dental care appointment canceled since they were put on hold in March, you should probably get to know Katrina Virgin.
A Kodiak-based dental hygienist, Virgin is also the president of the Alaska Dental Hygienists’ Association. In that role, Virgin has spent the last few weeks communicating with Alaska health care policy shapers in the state, as they decide which dental procedures will be allowed to take place, and when.
“It has been non-stop since March 13 for me. There are nights I do not go to bed as I am busy doing research, as well as answering phone calls, text messages, Facebook messages and emails from concerned dental hygienists all around the state,” said Virgin, who was first elected as ADHA vice president in 2017, and has served as the association’s president since 2018.
Virgin has written letters to national leaders, attended policy meetings and been in contact with Alaska Chief Medical Officer Dr. Anne Zink and Department of Health Social Services Commissioner Adam Crum to raise concerns about mandates.
She said mandate 15, which was issued by Gov. Mike Dunleavy April 15, was woefully inadequate for dental professionals, placing unrealistic demands on care providers and preventing Alaskans from accessing necessary dental services. When it was first released, it caused a flurry of confusion as dental professionals tried to adapt the requirements to their practices.
The mandate states that non-emergent procedures that generate aerosols require patients to obtain a negative COVID-19 test prior to receiving treatment. But limited testing capacity means that most of these aerosol-generating procedures are on hold.
“Some of the procedures that can be completed are exams, X-rays, oral cancer screening, and some dental cleanings,” Virgin wrote in an email. Procedures that require prior testing include crowns, veneers, cavity preparations, sealants and extractions, among others.
Virgin said that because of the testing burden, most dental offices in Kodiak and around the state are just beginning to open or haven’t opened yet. Trying to reach Kodiak dental offices by phone on Wednesday, none could be reached in person.
“I have not heard of any patients being tested prior to dental treatment here in Kodiak,” Virgin said. “The issue dental patients would run into is patients would require a note from the dental office to take to their provider who would then prescribe a COVID-19 test. Then the other hurdle would be obtaining a rapid response test.”
Cartridges for Abbott rapid ID testing devices are limited. Three medical facilities in Kodiak have the Abbott rapid testing capacity, which can provide results within minutes. These are the Providence Kodiak Island Medical Center, the Kodiak Community Health Center and the Kodiak Area Native Association.
“The traditional COVID-19 test has a turnaround of 3-5 business days, which does not satisfy the 48 hour window as mandated,” Virgin said. “The rapid response test is typically used for patients that are symptomatic, meaning signs and symptoms of possible COVID infection.”
“In order for Kodiak dentistry to go back to full activity we would need a minimum of 256 rapid response tests per day,” she said. This is an estimate based on dental offices seeing on average 24 to 40 patients per day, a low estimate according to Virgin.
That number of tests is unfeasibly high, even as testing providers in Kodiak have ramped up capacity and say they have ample ability to test their patients.
In response to the perceived hurdles created by mandate 15, a special committee in the Alaska Board of Dental Examiners has been working on creating a new dental mandate. However, she is unsure what the new testing requirements will be.
“If mandatory testing is required for many months it will potentially be a significant barrier to patients accessing dental care. If patients cannot access care, dental health declines, which can affect overall health,” Virgin said. “Running a dental office is also very expensive, thus if they cannot see patients, it may impact their ability to keep the office open. That would create more unemployment with dentists, dental hygienists, dental assistants, and dental staff being out of work.”
“If the state deems testing to be necessary, we want to support the decision, but we also need to assess the risk of declining dental treatment versus the benefit of requiring testing,” she said.
On top of testing requirements, she says adequate supply of personal protective equipment, or PPE, continues to be a major concern for dental clinics to return to full steam.
“I cannot speak to all dental providers, but the majority I have spoken to feel comfortable providing treatment if they have the necessary PPE,” she said. Dental care providers typically wear standard protective equipment, including gloves, a surgical mask and eye protection. “But during this pandemic the CDC recommends an N95 respiratory for procedures that generate aerosols, and they are very difficult to obtain, in conjunction with full-face shields and a gown.”
“With the limited amount of PPE, this could be a barrier to seeing the normal amount of patients we would regularly see. If there is not enough PPE, providers should not provide treatment,” Virgin said.
The state received a $3 million shipment of PPE, meant to last six months, according to Dunleavy. However, it is unclear if dental practitioners will benefit from the delivery, which was meant for Alaska hospitals and medical providers, the governor said.
According to Virgin, the risk of contracting COVID-19 in dental care settings may be lower than in medical care facilities. Thus far, no clusters of positive cases have been reported in dental settings or personnel, whereas many medical personnel have contracted the virus.
Dental settings regularly take precautions to decrease airborne contaminants, such as high volume evacuators (HVE), which use suction to draw in air while treating patients.
“Research indicates the HVE significantly reduces aerosols by 90-95%. On top of utilizing the HVE, dental providers per the Alaska Board of Dental Examiners are required to have patients complete a preprocedural mouthrinse of 1.5% hydrogen peroxide, which further decreases the potential for contaminated aerosols,” she said.
Dental offices are also conducting phone screening for patients prior to scheduling appointments. Patients are instructed to wait outside the clinic until the time of their appointment. They must hand wash upon entering a clinic, have their temperature taken and answer questions about their travel history, contact with known COVID-19 patients, and symptoms.
Virgin said she is also concerned that Alaska is reopening elective dental procedures too soon.
“Another common question that is asked is why are states including Alaska opening up dentistry when the CDC recommends to postpone elective procedures?” she said.
Even if care resumes as normal, she said the Alaska Board of Dental Examiners, the American Dental Association and the American Dental Hygienists’ Association all recommend that individuals 60 years and older or individuals that are immunocompromised postpone treatment if possible.
TESTING IN KODIAK
Carlie Franz, a communications specialist with Providence, said the hospital requires all surgical and obstetrics patients to be tested for COVID-19 prior to undergoing procedures, even if they are not experiencing any symptoms. She said the hospital has ample rapid testing capacity, but has reserved tests for hospital patients, and will not provide testing for non-PKIMC patients.
According to KANA Medical Director Dr. Elise Pletnikoff, KANA is testing both symptomatic and asymptomatic people. She estimated that one-quarter of all tests performed as of now are for asymptomatic individuals. KANA is encouraging every traveler to Kodiak’s remote villages to be tested prior to traveling from town to the village, to prevent the spread of the virus to locations without medical services.
Pletnikoff said she hasn’t heard any testing requests from dental patients from non-KANA dental offices, but said KANA is open to providing testing to any asymptomatic patients who require testing under the mandates.
“We really want to be very liberal in our testing,” Pletnikoff said. KANA has continued to receive a weekly supply of 96 Abbott testing cartridges, and she said they are not performing that many tests each week, meaning that the supply just keeps growing.
She estimated that KANA had performed about 200 tests as of Tuesday, up from 163 as of April 30.
“I think people are social distancing so well that common cold and other respiratory symptoms are less common now than they have been,” she said, adding that she believes those with symptoms have been diligent about seeking testing.
However, she noted that many people can carry COVID-19 without showing any obvious symptoms. Because of that, she said she believes the amount of testing performed in Kodiak should increase.