Over the past two decades, the world has experienced three outbreaks of very fatal coronaviruses including the current pandemic caused by SARS-CoV-2. COVID-19 has posed an unprecedented and dire situation for the world and has affected all facets of life. It also has provoked many people to reassess the cracks in our pre-existing governmental and societal systems and think about what the post-COVID world may look like.
The unanticipated cascade of events has overwhelmed the already strained healthcare systems in many developing countries as well, including Pakistan, where most of the adult population and more than half of the child population is experiencing dental decay, according to the Journal of the Pakistan Dental Association.
Also in Pakistan, more than 80% of people over the age of 45 of age have periodontal disease, and more than 20% of the population above the age of 60 is edentulous. Pakistan additionally suffers from the highest rate of oral cancer in the world. More than 90% of these dental diseases are untreated, however, as less than 5% of the population has access to complete dental care.
The Economic Impact
COVID-19 has been a key driver of the recent decline in Pakistan’s economy, leading to a temporary halt in its imports. This roadblock also manifested in the dental sector where dental healthcare personnel were unable to stock up on basic dental materials that were previously imported from foreign countries.
Liaqat Humayun, president of the country’s Dental Trade and Manufacturers Association, called it a “complete economic meltdown.”
“The impact we are seeing is huge. With institutions closed and prices of consumables soaring, it is time that the dental industry prepares itself for the unusual challenges [it will face] once this is over,” he said.
COVID-19 has left a devastating and lasting imprint on the dental industry, and with the uncertainty of the pandemic following a downward trajectory, it is difficult to ascertain the extent and severity of its long-term impact.
The professional future of dental practitioners and the sustainablity of their practices are serious concerns. Wages and clinic rentals have to be accounted for every month, even though there have been no revenues lately, causing a huge socioeconomic impact.
Real GDP growth is expected to decrease by 3% with downturns in services and manufacturing. Adding to this, the patient turnout rate in Pakistan has dropped by 84% compared to the pre-COVID period, according to a study conducted in a tertiary hospital setting in Lahore, according to the Pakistan Armed Forces Medical Journal.
The ADA reported a similar drop in patient turnout in the United States from March to June. But since then, 99% of American practices have reopened, with 65.3% of practices reporting 76% or more of pre-pandemic patient volume by August 24.
Access to PPE
Furthermore, scarce availability of existing resources due to supply chain disruptions and equipment nearing expiration compound the current scenario in Pakistan. Equally worrisome is the lack of adequate personal protective equipment (PPE) for frontline healthcare workers including masks, respirators, gloves, face shields, gowns, and hand sanitizer.
This pandemic has caused an upsurge in demand for preventive gear, as it has been an essential requirement for all healthcare providers not only to ensure their own safety but also the safety of their patients.
Plus, the importance of donning PPE cannot be refuted when dealing with patients in the current pandemic as well as if there is a potential resurgence in the fall and during any pandemics that we may experience in the future.
A cross-sectional study investigated the availability of PPE among doctors in the United States and Pakistan from April 8 to May 5, 2020.
According to the study, 87.6% of doctors in the United States reported having access to N95 masks and respirators, 79.6% had access to gloves, 77.9% had access to face shields and goggles, and 50.4% had access to full-suit gowns.
Meanwhile, doctors in Pakistan reported a significantly low availability of PPE, with only 37.4% having access to N95 masks, 34.5% having access to gloves, 13.8% having access to face shields, and 12.9% having access to full suit gowns.
Also, 50.6% of doctors in Pakistan reported being forced to work without PPE, compared to only 7.1% doctors in the United States.
The Impact on Academic Dentistry
Following the uninterrupted spread of the coronavirus in Pakistan, hospitals all across the country saw a massive influx of patients. The government primarily responded by converting any and all available places including dental clinics and schools to isolation centers and wards.
This extraordinary situation has immensely altered academic activity throughout the country. Medical and dental students are no longer able to perform their curricular duties and complete the allocated clinical credit hours that are necessary for the fulfillment of their respective programs.
Prolonged lockdowns and quarantine policies have taken a toll on the mental health of students as well. During this period, many students fell prey to fear and pressure associated with the pandemic. Dental schools must consider these issues and have mechanisms in place to provide psychological services to those who need them.
Research conducted in different provinces of Pakistan showed that 53.5% of dental students were going through high stress levels, 43.4% had moderate stress levels, while only 2.9% had low stress levels. Results from a similar study conducted on Turkish dental students showed high levels of stress and fear among them, with many considering changing their profession.
Also, most schools and colleges have had to reshape the academic system by shifting to virtual education, which may not be as intellectually and practically nourishing, especially for those in the medical sector. To make the most out of the current situation, schools should encourage students to engage in self-learning, make full use of online resources, and learn about the latest academic developments.
COVID-19 has impacted dental research as well, as all projects requiring clinical trials were suspended. Clinical trials require a broad range of samples that would jeopardize social distancing. Funding that was previously granted for these projects has now been redirected. This halt in research may have a negative effect on dentistry in the long term.
However, we must not forget that oral health researchers can still play a key role in the early identification and diagnosis of the disease by deciphering the mechanisms of dry mouth and loss of taste in COVID-19 patients. Preliminary data indicate that oral symptoms are prominent in many patients with COVID-19, especially in the early stages before other symptoms occur. Therefore, despite the current scenario, funding allocation must be fair, and oral health research studies with remote initiation and work should be prioritized.
The Government Response
To overcome COVID-19, the government should devise policies with health ministers, economic advisers, and dental professionals to prevent the plummet of the industry and compromises in the safety of healthcare workers. Accordingly, the government should allocate funds for contingencies to sustain the dental economy.
The pandemic has exposed significant gaps in the collective response of global healthcare systems to a public health emergency. Though dentistry has a relatively small part in the COVID-19 response, dental professionals should take this opportunity to assess the role of dental care, look into the future, and determine what we can improve to better serve our patients and protect our staff should a similar event happen again.
With the successive emergence of SARS-CoV in 2003, H1N1 in 2009, MERS in 2012, Ebola in 2018, and SARS-CoV-2 in 2020, global public health emergencies and infectious disease pandemics are no longer rare, once-in-a-lifetime events. As an integral part of the healthcare system, dentistry should be prepared to play a more active role in the fight against emerging life-threatening diseases. Dental education, research, clinical practices, and public health should consider key priorities during and after the COVID-19 pandemic:
- Improve public health emergency preparedness throughout the dental healthcare system.
- Proper donning and doffing of N95 respirators, surgical masks, and isolation gowns may need to be included in dental training curricula and dental practice routine.
- Ensure proper funding is directed toward the dental and medical education system.
- Ensure the availability of all kinds of necessary dental materials and equipment.
- Set up dental teleclinics to screen patients and determine whether they need to be seen in the office.
- Consider the use of precautionary measures during procedures such as preoperative mouthwash, rubber dams, and high suction.
- Use a properly maintained ventilation system.
- Strictly follow guidelines for the use of PPE.
- Initiate and participate in scientific research projects to discover the impact of COVID-19 and other infectious diseases on oral health.
- Increase research efforts in aerosol control in dental offices, including improving engineering control in dental office design.
- Consider negative-pressure dental operatories in academic health centers and dental school clinics since they are effective in reducing the risks of transmission of infectious respiratory diseases.
The current pandemic and future public health emergencies will require concerted efforts to overcome them, as well as courage and endurance to invigorate the healthcare system. We should work together today to ensure a safer, healthier, and happier tomorrow.
Dr. Khalid and Dr. Elahi are dental house surgeons at the Institute of Dentistry, CMH Lahore Medical College, Pakistan. They graduated as dental surgeons in 2019. They both have developed a keen interest in public health research and scientific collaboration and aspire to be involved in activities that amaglate these interests. Dr. Khalid can be reached at ayeshakhalid16.ak@gmail.com, and Dr. Elahi can be reached at savaizelahi123@live.com.
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