Dental Education in the Time of COVID-19 and Beyond

The dental profession is facing unique challenges in managing the health and safety of both patients and dental teams while providing care in an intimate setting, particularly when performing aerosol-generating procedures (AGPs). At the outset of the pandemic, most dental practices were either closed or limited to providing emergency care only. Dental education institutions faced these challenges while providing educational clinical experiences to novice dental student practitioners, who traditionally work two-handed without dental assistants primarily in open bay campus clinics designed to facilitate faculty supervision and instruction rather than control airborne droplets. Dental schools must mitigate risk faced by higher education institutions in providing a safe classroom, laboratory, and campus environment for faculty, staff, students, and visitors. Like other businesses and institutions in our communities, each dental school must comply with its state and local regulations, which vary significantly across the country due to local conditions, availability of appropriate personal protective equipment (PPE) and testing, political environment, and evolving knowledge regarding COVID-19.

This article will provide an overview of the initial responses by dental education institutions to the impacts of COVID-19 and their modifications of operations implemented to reopen all phases of their educational programs in this "new normal" environment. It will also discuss potential long-term impacts on dental education based on the experiences of four dental schools.

On January 9, 2020, the World Health Organization (WHO) announced 59 pneumonia-like cases in Wuhan, China, that may have been caused by a new coronavirus. On January 21, 2020, the CDC confirmed the first case in the United States related to the novel coronavirus SARS-CoV-2 in the state of Washington: a man in his thirties who developed symptoms after returning from a trip to Wuhan. On January 23, all 11 million Wuhan residents were under a strict lockdown. On January 30, the WHO declared a global health emergency as thousands of new cases spread, almost exclusively in China, but it was unclear how the virus was spreading among people. Although the United States had begun limited restrictions of travel from China effective February 2, and the following day declared a public health emergency due to the outbreak, senior dental students across the country were concerned primarily with completing any remaining clinical assessments, passing clinical licensure examinations, spring break activities, graduation exercises, and moving on to their first professional position or graduate residency program.

Although the United States was seeing just the tip of the iceberg when the first coronavirus-related death was confirmed on February 29in Seattle, Washington, outside of a few "hot spots," most of the country was assuming business as usual. At this time many dental students and faculty across the country were still planning to travel to the American Dental Education Association (ADEA) Annual Session starting on March 14 in National Harbor, Maryland. But on March 9, ADEA announced the cancellation of the meeting out of an abundance of caution due to the spread of coronavirus. When this was followed in close succession on March 11 by the WHO's declaration of COVID-19 as a pandemic and the declaration of a US national emergency on March 13, many dental schools quickly realized that an interruption in their educational programs due to this rapidly escalating crisis was imminent. On March 16, the American Dental Association (ADA) announced its recommendations for the postponement of elective dental procedures in response to the spread of the coronavirus, one of many announcements that came in rapid succession on a daily basis over the next few weeks. Governors, state dental boards, and state dental associations announced executive orders, temporary rules, and recommendations restricting the provision of dental care due to COVID-19.

As local restrictions were announced, affected dental schools typically responded by announcing temporary suspension of on-campus non-essential activities, including didactic classroom, simulation, and routine elective clinical patient care, and limited access to essential employees. For programs with extensive off-campus clinical rotations across wide geographic areas, suspension of activities was based on local site conditions. This initial response by schools provided a small window of time to assess the highly dynamic external environment and make an initial determination as to whether COVID-19 would have a short-term or long-term impact on campus activities, as well as time to plan for the temporary alternative delivery of curriculum. Dental schools also had to ensure that all temporary curricular changes were compliant with the accreditation standards of the Commission on Dental Accreditation (CODA).

Limited Campus Access and Dental Emergency Care. As dental schools realized that this would not simply be the duration of an extended spring break or a few snow days, it was necessary to quickly mobilize to plan and implement short-term alternatives for the remote delivery of curricular content, and develop a phased reopening plan to access campus facilities as soon as local conditions would allow. The guiding principle was to proceed with caution and to protect the health and safety of all faculty, staff, students, residents, and patients, starting with limitations to campus access. This meant not only that students would learn remotely, but like many other businesses, faculty and staff would work and teach remotely as well. IT departments were called upon to either set up secure remote access or allow faculty to move their digital curricular content and essential hardware to their remote work stations in order to create and deliver curriculum and continue with other administrative, scholarly, and service responsibilities.

Dental schools continued to provide some level of emergency dental care for patients of record in school clinics or hospital-based clinics as local conditions allowed, typically with faculty and staff members or experienced residents in graduate training programs. Like practicing dentists in the community, dental school clinics were faced with many unknowns on how to safely interact with others in an intimate indoor clinical environment and safely provide care for their patients. A number of dental schools that had access to appropriate clinical facilities and adequate PPE became the primary providers of dental emergency care for their communities, as local dentists were unable to provide care.

Remote Learning-Didactic Curriculum. To limit the disruption to student education, programs quickly shifted all didactic classes and seminars to virtual platforms such as Zoom, Google Classroom, and Microsoft Teams. Although many dental schools routinely record all didactic lectures or small group sessions, and some programs utilize remote learning for a portion of their curriculum, most dental schools have limited faculty members with the background and experience to plan an online course, let alone to do so in a matter of days. This challenged schools to provide faculty with intense training on the technical aspects of the virtual platform itself, but also on basic principles of instructional design for effective online delivery to promote student engagement and appropriate assessment methodology. In addition to a steep faculty learning curve, schools had to invest in new technology, faculty development resources, and support staff to act as course moderators to monitor chat rooms and provide technical support.

Equally challenging was for students to adjust to these new platforms-in particular, to exercise patience as faculty members learned to teach virtually in real time. In addition to technology adjustments, some faculty had difficulty titrating an appropriate amount of curricular content, overloading students with assignments and readings or simply not providing students a break from their monitor screens. Students also struggled with various remote learning environment issues, such as finding a quiet workspace with reliable Internet connectivity and bandwidth, as well as learning the technical aspects of the platform and managing virtual classroom fatigue. Commenting on the results of surveys and focus groups with faculty and students, Diana Messadi, DDS, MMSc, DMSc, Associate Dean for Academic Affairs at University of California Los Angeles (UCLA) School of Dentistry, said, "We found that students learn best through asynchronous teaching techniques, which means providing prerecorded lectures that students watch before attending the live discussion sessions. The best live session results were achieved when faculty and students were both engaged through having everyone's cameras turned on and being efficient with the time allotted for the Zoom session." Additionally, exclusive use of remote learning platforms creates a challenge to develop strategies to address the loss of socialization for students, which occurs more naturally while they are together on campus.

Remote Learning-Resequencing and Virtual Clinic Sessions. As it became clear that direct patient care would be delayed for an indefinite period of at least several weeks, many programs looked for alternative strategies that could be implemented within days to allow students the ability to progress in their programs. Some dental schools provided students with portable handpiece units and typodonts to allow for remote simulation sessions and continued hand skill development. Many programs opted to resequence didactic classroom and seminar curriculum forward in lieu of cancelled clinic or simulation clinic sessions, which would allow the students additional clinic or simulation clinic time in the future when patient care and access to campus resumed. Many dental schools utilized the additional didactic time to provide review sessions or advanced curricular content. For upper-class students who had significant clinical patient experiences, this provided an opportunity for faculty to leverage those experiences and provide content more typically taught at the post-graduate level. For D1 and D2 students, the additional in-depth content could better prepare them for the array of patient-care experiences they could expect to encounter as clinics reopened.

Another strategy was to develop virtual clinic sessions, where faculty and students discussed their current clinical cases in a study club format, providing the opportunity to integrate and apply biomedical, clinical, and behavioral sciences. For example, at A.T. Still University's Arizona School of Dentistry & Oral Health (ASDOH), students were scheduled into their virtual clinic sessions with faculty facilitators in the comprehensive care units and in the specialty areas where they were required to create clinical case presentations, adhering to a standard case presentation template provided by the faculty. The faculty facilitators also created a pool of clinical questions for assessment, creating a system of keywords to link student cases to the relevant current literature.²

Development of Phased Reopening Plans. Dental schools developed task forces to plan and develop protocols consistent with CDC guidelines and best available evidence. Such protocols included health screenings to enter campus buildings, development of circulation pathways and social distancing, rules for use of PPE, physical plant modifications, management of ventilation and airflow, aerosol mitigation, operatory cleaning and disinfecting, and COVID testing. With the realization of the inevitability of COVID-19 exposures on campus, reopening plans typically included the creation of faculty/staff/student teams to limit impact when a COVID-positive person entered campus and to facilitate a system analogous to contact tracing. As was the case for all types of institutions throughout the country, the dynamic environment related to knowledge of COVID-19 meant that protocols could not necessarily be based on 100% evidence-based research, nor on federal, state, and local guidelines, which were well-established. Many protocols reflected the collective decisions of faculty who were applying sound scientific principles to the available evidence each day. Thus, guidelines were being continually reviewed and updated based on what at times were daily changes in either federal, state, and local regulations or orders, CDC guidelines, university guidelines, or other available evidence.

Dental schools are now operating in the so-called "new normal" due to the COVID-19 pandemic. The time period is indefinite, but dental schools are planning for continuation of pandemic-related changes through at least the end of the academic year in June 2021. Some of the new protocols outlined below to mitigate the risk of transmission will no longer be necessary by the end of the pandemic, but many are anticipated to be long-term changes in how to safely provide care to patients and effectively educate students. Table 1 provides a summary of COVID-19 mitigation strategies and protocols implemented at four dental schools in the United States as of the time of this writing.

Remote Learning for Didactic Curriculum. Dental schools continue to mitigate the risk of spread of COVID-19 by utilizing online learning platforms for most didactic content. Faculty and students have continued to adapt to this methodology, and in some situations it may now be considered a preferred platform to provide fact-driven content asynchronously. Many challenges remain, such as the ability to proctor students while they are taking high-stakes summative examinations. For this reason, some dental schools have increased the use of formative assessments and activities while students are working remotely and scheduled high-stakes examinations on campus in socially distanced settings.

Access to Campus for Simulation Activities. Except for ongoing dental emergency care in clinical settings, most dental schools reopened their campuses initially in late spring or early summer for their dental students to participate in simulation activities in clinics or simulation laboratories. This was particularly important for many programs, as it provided an alternative pathway for senior dental students to complete outstanding assessments and graduate in a timely manner. It also enabled other students to avoid falling further behind in hand skill development and make up for the many weeks already lost.

As dental schools slowly reopened their campus facilities, they followed similar guidelines for faculty, staff, and students to return to campus based on CDC recommendations, such as:

• Screening for all campus visitors, including a health questionnaire on symptoms associated with COVID-19 (fever, cough, shortness of breath, sore throat, etc). For faculty, staff, and students daily online forms are utilized prior to coming on campus, and individuals should not come to campus if any symptom is reported; individuals are expected to consult with either a campus clearinghouse or their primary care provider prior to returning. Daily check-in protocol also includes a temperature check, with no access allowed if the temperature recorded is greater than 100°F. 
• Social distancing and use of face masks required at all times on campus. Signage and floor markings should be installed to facilitate social distancing and all rooms posted with maximum capacity based on size and layout to comply with social distancing guidelines.
• Limited access and movement while on campus, with all parties expected to leave campus without congregating or meeting before and after planned activities. Some programs developed circulation pathways to control spacing and limited elevator and restroom capacity.
• Strict compliance with hygiene, including frequent hand washing, use of hand sanitizer, appropriate don/doff protocols for PPE, and continuous cleaning of high-touch surfaces throughout the campus buildings.

As dental schools across the country cautiously reopened in late April through June, not all schools were able to implement routine testing requirements for faculty, staff, students, and patients due to a lack of availability and reliability as well as cost of testing. The University of Illinois Chicago (UIC) College of Dentistry was able to continue providing routine tests, as it utilized a rapid saliva test developed at the University of Illinois Urbana-Champaign designed to mitigate outbreaks on campus while avoiding drawbacks associated with standard nasal swab tests such as high cost, supply chain issues, and long wait times for results. UIC now offers this test, free of charge, to asymptomatic members of its colleges, who are able to make appointments electronically. The saliva sample collection is painless and takes only 3 to 5 minutes, and results are disseminated via campus email within 24 to 48 hours. Individuals who test positive are provided with follow-up instructions. Additionally, UIC utilizes a contact tracing and epidemiology program, based in its School of Public Health, to provide contact tracing to students and employees, particularly those engaged in hands-on clinical work who test positive for COVID-19 either in their clinic or via testing through their personal healthcare provider.³

For most dental schools, the reopening of simulation laboratories with fixed workstations required creative solutions to meet guidelines for mitigation of risk, such as social distancing and appropriate use of PPE. Some dental schools, including UCLA and ASDOH, achieved social distancing by utilizing every other simulation workstation and staggering occupied seats between rows. At UCLA, this strategy resulted in a longer day (ie, 7:00 AM-8:00 PM) to allow for an additional session on weekdays as well as added Saturday sessions. ASDOH increased daily utilization of its simulation lab to create two 5-hour sessions each day (ie, 7:30 AM-12:30 PM and 1:00-6:00 PM), one for each half of the class, each with a team of faculty. Students were encouraged to be efficient with their time. The end result was that exercises that previously were completed in two 4-hour daily sessions were completed in one 5-hour session.

A.T. Still University's Missouri School of Dentistry & Oral Health (MOSDOH) initially implemented scheduling similar to UCLA, with three daily sessions and Saturday sessions, but the school then completed renovations in which plexiglass barriers were added between each workstation to eliminate the need for social distancing and allowed a return to pre-COVID scheduling. MOSDOH also implemented new digital technology to enhance safety, streamline the grading/feedback process, and improve efficiency during each session. All schools had strict requirements for faculty, staff, and students to wear appropriate PPE at all times while in the simulation lab, including at least a level 3 surgical mask and face shield. In addition, each program identified teams of faculty and students to control the impact of a COVID-positive individual and to facilitate contact tracing.

In addition to the use of simulation labs for typodont exercises, some dental schools utilized their clinical operatories for simulation activities, both prior to reopening for patient care and integrated with patient care in the clinical operatories. These strategies were utilized at ASDOH, MOSDOH, and UCLA for multiple reasons. Two primary reasons were to provide increased opportunities to students to practice and maintain clinical skills prior to patient care, and to prepare for the challenge of clinical licensing examinations, given that the simulation clinics were being utilized to their new capacities. Another reason was to allow faculty the opportunity to test out new potential protocols in a simulated environment before implementing them with patients in the clinic. These piloted protocols included new infection control don/doff procedures, efficient provision of faculty supervision and feedback while working with limited PPE, and utilization of four-handed dentistry with student "runners" who were responsible for moving supplies and equipment between the operatory and dispensing areas. Students needed time to adjust to providing care with new levels of PPE, understand how to work safely with new protocols, and develop significantly more confidence and speed to provide efficient care for their patients. In addition, a significantly higher level of efficiency became necessary to gain more clinical experiences in less time to make up for previously lost time, offset the decreased clinic capacity due to social distancing practices, and compensate for the loss of chairtime due to operatory cleanup and turnover. Finally, COVID-19 caused the shift of clinical licensure examinations to manikin-only assessments, and many state boards approved their use, at least temporarily. Therefore, it became necessary for students to maintain their skills in order to remain prepared for the changing landscape of licensure.

Reopening Clinics. The timing for reopening dental school clinics has been driven by many local factors, including compliance with local orders, completion of physical plant changes, training related to new protocols, and availability of appropriate PPE and/or COVID testing. Identifying a reliable supply chain for N95 respirators was a significant challenge for many dental school programs, particularly those that are not part of an academic medical center, which is the case for MOSDOH and ASDOH. In addition, these dental schools needed to develop their own respiratory safety programs and properly fit-test all clinical faculty, staff, and students. By July 2020 most dental school clinics were open but operating at less than 100% capacity. Table 2 highlights some of the ongoing COVID-19-related challenges for dental schools.

All of the protocols for access to campus noted above are applicable to the reopening of campus clinics. Patients are expected to be screened, wear masks, and maintain social distance consistently with dental school faculty, staff, and students. Reception areas have been reconfigured to allow for social distancing, patients are being instructed not to bring other guests with them, and, in some cases, patients are being asked to remain outside the building if reception areas have reached capacity. Programs may be staggering start times of appointments in a session to decrease the potential for overcrowded public spaces. Patients are also being asked to notify the dental school if they become symptomatic or COVID-positive within 2 days of their clinic visit, which will trigger contact-tracing protocols if necessary.

Dental school clinics are typically designed with mostly open bays of operatories, for both efficiency of space and to facilitate faculty supervision of multiple student providers. At the time of this writing, there continues to be limited evidence on the extent of risk in the dental environment. For example, what, if any, pre-procedural antimicrobial mouthrinse is effective at reducing the viral load of SARS-CoV-2? Dental school clinics follow all CDC guidelines, but there is a need for more definitive research. Dental schools generally tend to proceed with the utmost caution, and their clinic protocols can vary somewhat across the country as programs take steps to maintain health and safety during patient care. It is likely that some of the clinic protocols currently in place will no longer be considered necessary as our knowledge about the spread of the virus improves.

Table 1, to reiterate, provides a summary of the safety preparations implemented at four dental schools. One strategy has been to develop a system to categorize dental procedures based on potential risk due to creation of airborne contamination or aerosols. This drives the level of PPE required for the providers and the need to provide care in an operatory with appropriate isolation (eg, closed room or segregated location), engineering controls (eg, high-efficiency particulate air [HEPA] filtration units, extraoral high-volume evacuation [HVE], needlepoint bipolar ionization), and administrative controls (eg, runner, four-handed dentistry, don/doff protocol, rest time between patients, etc). For many schools, this amounts to a two-category system: AGPs versus all other procedures. The CDC defines AGPs as procedures that utilize ultrasonic scalers, high-speed handpieces, air/water syringes, air polishing, and air abrasion. At ASDOH, MOSDOH, UIC, and UCLA, providers conducting AGPs are required to wear an N95 respirator rather than a level 3 surgical mask, and the procedure must be scheduled in an appropriate chair that is properly isolated (eg, in a closed room, or has a physical barrier such as a curtain system or plexiglass) or appropriately distant in an open bay environment (at least one open chair between chairs). All other procedures may be done in an open bay environment wearing standard pre-COVID PPE with a face shield.

At UCLA, the faculty have developed three categories of procedures and associated PPE: non-fluid procedures requiring the standard PPE used pre-COVID, along with a face shield; low- to moderate-fluid-producing procedures requiring additional PPE; and high-fluid-producing procedures requiring the most precautions, including head coverings, surgical booties, face shields, N95 masks, gloves, and gowns. UCLA has also developed a reusable extraoral HVE device as a supplement to existing HVE to further reduce aerosol particles during dental procedures. Each device connects to an additional standard high-vacuum line that has been installed in each operatory. At MOSDOH and UCLA, each dental operatory now has two HVE units. UIC installed HEPA filters, as well as 50 needlepoint bipolar ionization devices, in the ceilings of the dental clinics in an effort to provide viral risk mitigation by killing pathogens and improving air quality.⁴ Installation of these devices is aimed at minimizing aerosols that are generated during patient care and, thus, improving safety for patients, staff, students, and faculty.

Dental education-and the profession of dentistry-is facing numerous challenges in this time of COVID-19. While many of these challenges are not a direct result of the pandemic itself, the crisis has amplified them and brought them to the forefront. The pandemic has introduced financial challenges with reduced capacity in dental school clinics to generate clinic revenue, increased capital costs to redesign clinics and purchase new equipment, and added expenses for PPE. Pre-COVID dental education, however, was already struggling with the cost of programs, high tuition, and overwhelming student debt loads. This crisis has exacerbated the challenge of providing students with sufficient depth and scope of clinical patient experiences to enable them to be practice-ready upon graduation. Pre-COVID, schools had been struggling to provide students with sufficient clinical experiences, failing to shift inefficient clinic education models to true patient-centered clinics as recommended in the Institute of Medicine's 1995 report, Dental Education at the Crossroads.⁵ The crisis has highlighted the challenges of creating innovative delivery of curriculum through asynchronous and synchronous methodologies. Before the pandemic, dental education institutions had already been struggling to change CODA standards that are based on traditional concepts of education, find adequate time and resources for faculty development, and collaborate with other dental schools to create shared curricular content. The current crisis has highlighted the challenges associated with graduates becoming licensed without passing an examination on a live patient; however, pre-COVID dental education had already failed to eliminate state dental board reliance on patient-based clinical examinations. COVID-19 highlighted the importance of recognizing dentistry as an integral part of our healthcare system after dentists were initially asked to cease providing care while other healthcare providers fought on the frontlines. We had already, however, made inadequate progress in interprofessional education, expansion of the scope of practice, and development of collaborative practice models. Through the lens of traditional dental educational models, these challenges seem particularly daunting; however, viewing these challenges through an optimistic lens, a number of dental educators are recognizing opportunities to positively leverage the disruption COVID-19 has caused.^6,7

The pandemic has prompted various creative ideas and actions that are changing how dentistry is taught. These changes could revolutionize the delivery of dental education while creating opportunities for greater access to the dental profession. Deans from the 68 dental schools in the United States continue to focus on innovative ways to ensure the delivery of quality dental education that meets the needs of each dental program. During this pandemic period, the delivery of live classroom lectures has dwindled to near obsolescence because of the need for physical distancing. The availability of mobile dental handpieces is creating opportunities for remote preclinical simulation exercises, while multimedia electronic platforms are generating opportunities to increase community outreach programs to reach an even greater audience and promote information on oral health literacy, highlight the interconnection between oral health and systemic health, and promote ways to access oral healthcare. As online learning, recorded lectures, and independent learning gain more acceptance, the standard of asynchronous competency-based education seems to be well within reach for dental schools. To move the pendulum even further toward change, dental school administrators must be proactive in engaging the Commission of Dental Accreditation, the Department of Education, and the Commission on Higher Education to further capitalize on these pandemic-induced changes to transform and advance the dental profession. In addition to revolutionizing dental education, might the pandemic propel dentistry to return to its genesis as a specialty of medicine? This conversation is gaining traction, as leaders from both professions are realizing the interconnectivity of their fields and the need to bridge the divide to achieve greater success and better treatment outcomes for patients.⁸

The high cost of dental education has been a major concern for dental school deans, ADEA, and stakeholders, because it restricts access to the dental profession, especially for individuals from disadvantaged backgrounds. Some of these forthcoming changes could result in different pathways to earn a dental degree, such as an accelerated 3-year track, the traditional 4-year track, and an extended 5- or 6-year track, thereby creating opportunities for reduced cost and greater access to the profession for disenfranchised groups. The opportunity for a student to complete part or all of the first year of the dental curriculum virtually, or from home, could lead to reduced costs associated with moving, living, and accommodations for this portion of dental school. Certainly, the Department of Education would have to make sweeping changes regarding the regulation of financial aid or Title IV funds. The revolutionization of dental education would necessitate taking a multifaceted approach, and each entity will need to be willing to collaborate to bring about changes if the goals are to make dental education more affordable, develop different pathways for obtaining a dental degree, increase access for disadvantaged groups, and improve whole-person health.

To merge dentistry with medicine, changes must be made on the business side regarding dental coding, billing, and compensation to match that of medicine. This will require a major undertaking with policymakers and special interest groups to merge the Current Dental Terminology Procedure Codes (CDT) and the International Classification of Disease (ICD-10) codes that are used in medicine. The outcome could have a significant public health impact, as all diseases affecting the body would be viewed as diseases and not categorized strictly as relating to medical or dental. The ultimate beneficiary of such changes will be the patient who will receive better care as interprofessional education and interprofessional collaborative care become the new standards of care. Of paramount importance to this plan is the eradication of yearly limits for dental treatments, thus creating greater access to oral healthcare with better dental and overall health outcomes.

The future of dentistry looks bright, but the opportunity to capitalize on these changes will not last forever.

The authors acknowledge and thank Jack Dillenberg, DDS, MPH, Dean Emeritus of the A.T. Still University Arizona School of Dentistry & Oral Health, for his assistance and comments during the preparation of this article.

Leonard B. Goldstein, DDS, PhD
Assistant Vice President for Clinical Education Development, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona; The ATSU Center for the Future of the Health Professions

Robert Trombly, DDS, JD
Dean, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona

Dwight McLeod, DDS, MS
Dean and Professor, Missouri School of Dentistry & Oral Health, A.T. Still University, Kirksville, Missouri

Jeffrey M. Goldstein, MBA, PhD
Director, Clinical Dental Center, UCLA School of Dentistry, Los Angeles, California

Georgia Lymberopoulos, DMD, MPH
Clinical Assistant Professor, University of Illinois College of Dentistry, Chicago, Illinois