Securing Public Trust: Dentistry, SARS-CoV-2, and “Testing for Tomorrow”

The public's response to a catastrophe of any type is greatly influenced by public trust.¹ This influence is manifest in multiple ways, including, but certainly not limited to, severity and transmissibility of disease, willingness to adopt interventions, and information-seeking behavior. All of these factors have profound influence on containing and managing infectious disease outbreaks. Situations resulting from the SARS-CoV-2 pandemic have deeply undermined the public's trust. These situations include the dissemination of conflicting information, the withholding of care, and the devaluating of dentistry as a profession.

Conflicting and/or inconsistent messaging from government leaders, scientists, healthcare organizations, and healthcare professionals themselves has eroded the public's trust,² yet trust in those who provide information is a major predeterminant of compliance with recommendations and policies.³ One clear example of the impact of conflicting messaging is compliance with regard to wearing facemasks. Over the course of the pandemic, senior government officials have shifted recommendations from not needing masks, to masks being critical, to the need for double masks.⁴ Even President Biden and Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, have at times worn double masks while some high-ranking officials have argued that double masking is only needed in high-risk situations.

Among the troubling SARS-CoV-2 challenges was the recommended suspension of all but essential care, first by the US Government and followed shortly thereafter by the American Dental Association (ADA).⁵ What was expected to be a 2-week moratorium on the provision of both medical and dental care extended into many months. Effectively, except for emergencies, this suspension withheld care during that time, undermining the perceived value of primary healthcare as an essential component of population health. Simultaneously, many dental schools suspended classes and strictly limited or stopped providing clinical care, severely restricting care available to a large cadre of people who already had few alternatives for seeking treatment elsewhere.⁶ The situation was further exacerbated by millions of people losing medical and dental insurance as they became unemployed.⁷ While at least some people have now re-entered the workforce, this does not necessarily translate to restoration of healthcare benefits. Collectively, these situations negatively impacted preventive care, forced hard decisions by patients about the priority for dental care, and transformed what might have been intervention procedures into more complex treatments (eg, endodontic treatment to extraction or orthodontic growth management to surgical correction).

Not only was the health of the public damaged when dentistry was forced to shut down, but the reputation of the profession was substantially damaged by the de facto label that dentistry is "non-essential" care. The ADA subsequently asserted that dentistry is an essential element of healthcare.⁸ However, trust is not easy to rebuild. While dental practices began reopening in May 2020, by mid-November most practices were operating at only 75% of their maximum capacity, strongly suggesting that even prior patients were not yet ready or able to seek dental care.⁹

Dental professionals have long been ranked among the most highly trusted professionals.¹⁰ Despite the SARS-CoV-2 challenges, dental professionals can be a key factor in rebuilding public trust, becoming a "go-to" credible source of information. Testing, particularly the "Testing for Tomorrow (T4T)" initiative, is an important step in the trust rebuilding process.

Beginning in March 2020 several organizations across the country began discussing how they might come together to improve the ability of the dental profession to "reopen" safely and thereby rebuild confidence in the dental care delivery system. These organizations comprised the University of California at San Francisco, the University of Michigan (UM), Temple University, the University of Pennsylvania, Rutgers University, New York University, Henry Schein, Inc., and the Santa Fe Group. The representatives from each of these organizations quickly realized that deployment of a point-of-care (POC) test for SARS-CoV-2 would be a critical element in the ability of dental, or for that matter, any clinical practice to open more quickly and safely. The geographic dispersion, reputations, and collaboration of these eight primary organizations involved in the effort were considered to be advantageous versus any one organization striking out on its own, and the groups worked together as the Testing for Tomorrow (T4T) Collaborative. In addition, a small set of advisors from Harvard University, SHIFTLife Inc., and Yale University were consulted. A complete list of all T4T participants is available.¹¹

T4T began evaluating available POC SARS-CoV-2 tests on a platform-neutral basis, meaning that any manufacturer that could provide an accurate POC test would be considered. Several of the collaborating partners independently evaluated available tests, but none of the tests met all the goals for simplicity, accuracy, and speed that were considered highly desirable by the Collaborative. A chart of Emergency Use Authorization (EUA)-approved molecular, antigen, and antibody tests that were considered is available, as are descriptions of the pros and cons of the various tests evaluated and the goals of T4T.¹¹

Absent an ideal POC test for deployment in the various school clinics, the academic institutions moved forward independently, but in consultation with one another, to open their respective clinical facilities utilizing a set of safety guidelines, which generally included an appropriate mix of the following: personal protective equipment (PPE), social distancing, symptom checking, environmental improvements, aerosol minimization, SARS-CoV-2 testing (consisting of an assortment of molecular tests, antigen tests, and antibody tests, often conducted in concert with the parent institution), contact tracing, enhanced disinfection protocols, and quarantine when appropriate. All clinic operations were eventually able to reopen safely using some combination of these approaches.

It is now clear that private practitioners applied a comparable set of practice modifications to reopen their offices safely, and while dental visits have not yet reached pre-pandemic norms, they are approaching normalcy. Indeed, while each T4T participating institution reported that the new procedures, both testing and expanded infection control, were well received by patients, one participating institution (UM) conducted a formal evaluation of patient reactions (Figure 1), reporting that: "Knowing the results of an antibody test would decrease the level of stress and anxiety in 67% of respondents. Over 80% found a COVID-19 test received in a dental setting acceptable, were ‘definitely' satisfied and would ‘definitely' recommend it to a friend, family member, or coworker."¹² Thus, conducting such general health-oriented testing appears to be an important tool in enhancing public trust in dentistry.

Public trust is critical for influencing response behaviors to infectious diseases, including people's perception and understanding of the severity and transmissibility of the disease, their willingness to adopt interventions, and the information they seek and value. While the SARS-CoV-2 pandemic has confused and troubled the public and healthcare professionals alike, the latter are responsible for utilizing their respected positions to lead initiatives to restore and engender trust in science, healthcare, and public health, and thereby improve the likelihood of accelerated recovery from this and future pandemics. Three calls to action can help rebuild the public's trust:

Call to Action 1: Healthcare professionals of both medical and oral health, together and separately, must be outspoken and advocate for clear, culturally sensitive, science-based, consistent health information and messaging to inform both policy and public-facing information.Both the public and policymakers need disease-specific knowledge to battle infectious diseases and catastrophes like SARS-CoV-2.¹² Unfortunately, like many catastrophes, SARS-CoV-2 appeared as a new, previously unknown virus, and the knowledge base for this disease is continuously and rapidly evolving as the pandemic progresses.

A confluence of factors makes this call to action a challenge-and a priority. "Best guesses" based on similar but different viruses often were the basis for early recommendations. As more information becomes available, messages and information evolve and change, often conflicting with previous messages. Leaders in the first year of the pandemic sidelined scientific institutions as key political decisions were made without or despite evidence.² Past skepticism around vaccine safety along with the speed of development, introduction, and emergency use authorization of testing systems and vaccines have been cause for concern among the public.^13-16 The huge number of SARS-CoV-2-related peer-reviewed scientific articles challenges the capacity of the public, professionals, and policymakers to digest all of the information.¹⁷ Strategies are urgently needed to synthesize the information and both articulate and advocate clear, culturally sensitive, science-based, consistent health information and messaging to inform both policy and public-facing communication.

Call to Action 2: Oral and other healthcare professionals must be fully integrated into the planning of the response and the response itself to future emergencies and pandemics by contributing the full scope of their training.Integrating oral healthcare professionals into emergency and pandemic response plans adds a well-trusted, knowledgeable, highly skilled human resource to what is often a resource-limited situation. Dental professionals are well versed in healthcare, offering significant skills in managing trauma, suturing wounds, giving injections, performing screening tests, and calming worried well patients.^18-21 The National Health Service has effectively redeployed dental professionals to deliver SARS-CoV-2 vaccines in the United Kingdom.²²

It is perplexing that pharmacists, firefighters, and emergency medical technicians have been tapped to provide vaccines,^23,24 while dentists, dental therapists, and dental hygienists have been overlooked despite their being very well practiced in delivering injections for anesthesia. The scope of dental practice needs to be extended nationwide, permitting oral care professionals in more than just a few states to deliver tests and vaccines. Oral care professionals, who are generally well respected and often professionally active in their communities, can be a resource for casual health information. As such they can contribute to early diffusion of public concerns. Furthermore, because they are widely dispersed throughout the nation, they can become an important resource for tracking emergence and evolution of infectious diseases.

Healthcare professionals bring much-needed expertise and insight into emergency situations. Fully integrating them into responses to emergencies and pandemics is critically important.

Call to Action 3: Oral health professionals must embrace the value of and implement specific actions to define and drive policies for bi-directional integrated oral health and primary care.Oral and systemic health are intimately intertwined. Oral diseases share common risk factors with major noncommunicable disease and are linked with more than 50 systemic diseases,²⁵ many of which have been shown to be COVID-19 co-morbidities.^26-29 High oral bacterial loads have been associated with post-viral SARS-CoV-2 complications,^18,30 and high bacterial loads and/or superinfections have been found in 50% of SARS-CoV-2 deaths.^31,32

Millions of Americans see an oral health professional each year but do not see a physician. Dental professionals screen health conditions that are relevant to both oral and overall health.^33,34 Dental practices are equipped to monitor many patient conditions and could provide screening, diagnosis, and follow-up services for at least some common ailments. These screenings may be a cost-effective use of health system resources; it has been estimated that dentists providing POC screening for diabetes, hypertension, and hypercholesterolemia could save the healthcare system between $5.1 million and $65.3 million annually.³⁵

Whole-body care is vital. While dental offices are able to screen for, diagnose, and monitor patient conditions, it is equally critical that primary care practices reinforce the importance of oral hygiene and other oral health promotion activities. Oral health should be an integral part of primary care workflow, standards of care, and documentation.³⁶ Policies that facilitate bi-directional integrated oral and primary healthcare would be advantageous to patients, healthcare providers, and the healthcare economy.

T4T demonstrated the power of collaboration to enhance decision-making in a time of a crisis. Indeed, members of the participating institutions commented that the availability of dedicated colleagues to review various ideas and approaches for the safe reopening of clinics enhanced decision-making at the local level. In addition, regular meetings of T4T provided ideal opportunities for the presentation of new technologies for best managing the pandemic. Most participants in the Collaborative would not have had access to these evolving technologies had they elected to "go it alone." Thus, such collaborative structures should be considered an important mode to deal with future crises. While T4T did not meet its primary objective of identifying an ideal POC SARS-CoV-2 test, it did give each participant an edge in managing through the pandemic on an institutional basis.

Importantly, members of T4T are now developing an approach to POC testing in the dental office that may prove to be highly valuable in the long term. Specifically, the Collaborative is evaluating whether it should continue to evaluate more broadly based POC tests, with a goal toward integrating oral care more completely into healthcare. For example, HbA1c, oral cancer tests, human immunodeficiency virus, and Zika evaluations, among many others, all can be conducted with saliva or a small blood sample. At the time of this writing, there are three major meetings in development to promote better integration of oral care into healthcare, and POC testing can be an important component of any such sea change in healthcare delivery. Such integration should be welcomed by patients and enhance trust in the skills of the dental profession.

E. Dianne Rekow, DDS, PhD Professor Emeritus and former Executive Dean, King's College London Dental Institute, England, now the Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London

Michael C. Alfano, DMD, PhD Member, Santa Fe Group, New York, New York; Professor, Dean, and Executive Vice President Emeritus, New York University, New York, New York