March 2021 Volume LVI Number 2

 
 
 
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Policy Center Updates

March 2021 Volume LVI Number 2

Check Out New Webpage Resources Relevant to Your Practice'
The Policy Center has updated its pages on the AAPD website with new resources, re- search and information that you will find pertinent to vital areas of your practice. Check it out under Policy Center under Research at www.aapd.org. Here’s a preview of what is featured on each page.
 
Dental Workforce. This webpage offers up-to-date information about how pediatric dentists practice in the U.S., including practice type, participation in private and public insurance programs, dental fees of pediatric dentists and general practitioners na- tionally and by region, and significant trends in characteristics of the pediatric dental workforce.
 
Notable content:
  • AAPD Survey of Dental Practice. In 2017, the AAPD conducted a survey among its members to collect data on central aspects of pediatric dental practices. Data in- clude information on such subjects as perceived busyness, geographic variations in the workforce, and charitable care.
Children’s Health Data. This page features resources on children’s oral health and general health status. You will find information on topics ranging from dental caries and periodontal disease to access to preventive dental services, including socio-demograph- ic indicators for oral health disparities such as economic status, geographic location, and race and ethnicity.
 
Notable content:
  • Child Snapshot Slide Presentation. Updated in late 2020, this slideshow presents a wide breadth of statistics on key indicators of American children’s health and well- being, as well as access to and use of dental services.
  • State of Little Teeth Report, 2nd Edition. This 2019 report examines the causes and im- pacts of dental diseases among children. Additionally, it explores various remedies to these issues provided by pediatric dentists, patients, and national policy leaders.
Technical Briefs. The AAPD has published numerous technical briefs on topics ranging from the importance of early dental visits to Medicaid coverage and innovations in tooth decay treatment.
 
Notable content:
  • Treating Tooth Decay: How to Make the Best Restorative Choices for Children’s Health. This technical brief explores the various restorative choices for children’s teeth, includ- ing stainless steel crowns, supported by patient-friendly visuals. It offers solutions for pediatric dentists, parents, policy leaders and insurers to help all children receive the best treatment using proven restorative choices.
  • Are Your Kids Covered? Medicaid Coverage for Essential Oral Health Benefits. This technical brief, designed as an advo- cacy resource, discusses the importance of state Medicaid coverage of selected dental procedures, shows state-by- state coverage of each of these CDT codes, and identifies areas for improvement in coverage for oral health services.
Oral Health in Primary Care. This page includes resources on the integration of oral health care into primary healthcare settings. By incorporating oral health promotion into well-child visits, healthcare providers can collectively streamline caries risk assessment and more effectively promote the importance of oral health to parents and caregivers.
 
Notable content:
  • Predictive Model for Caries Risk Based on Determinants of Health Available to Primary Care Providers. The AAPD developed a model to gauge the risk of oral disease at the time of a patient’s first dental visit based on information collected at early well-child visits. This model can help primary care providers provide more effective early caries risk assessments.
Non-Dental Provider Issues. AAPD’s advocacy efforts are built on oral health policies and evidence-based clinical practice guidelines that promote the delivery of safe, comprehensive oral health care within a Dental Home. The Dental Home model is based on dentist-directed care, which means the dental team works under the direct supervision of a pediatric dentist to in- crease the dental office’s capacity to serve more children while also preserving quality of care.
 
Notable content:
  • Maryland Dentists’ Perceptions and Attitudes Toward Dental Therapy. Published in July 2020, this report shows recent information on the viability of dental therapy to address concerns about access to oral health care for underserved populations. This data indicate that the majority of dentists oppose the use of dental therapists to address the dental health needs of at-risk children and would not employ dental therapists in their offices.
Medicaid/CHIP Reform Issues. AAPD advocacy supports programs that provide adequate dental benefits, including maintenance of the Medicaid EPSDT benefit. It further supports market-based payment rates to maximize patient and provider participation, thereby alleviating oral disease among millions of children.
 
Notable content:
  • Dentist Participation by Medicaid or CHIP. This handy graphic, published by the ADA Health Policy Institute in August 2020, displays breakdowns of dentists participating in Medicaid or CHIP by state, gender, age, specialty, race/ ethnicity, and affiliation with a dental service organization. It also shows the national percentage of all dentists who participate in Medicaid or CHIP.
  • Estimating the Cost Savings of Preventive Dental Services Delivered to Medicaid-Enrolled Children in Six Southeastern States. This paper explores long-term impacts of early dental intervention on state Medicaid expenditures. The study found that Medicaid cost savings from using topi- cal fluoride and sealants before caries-related treatment ranged from $1.1 million to $12.9 million/year in the states studied.
Evidence-Based Dentistry (EBD) Committee Update
The EBD Committee oversees the development of new evidence-based clinical practice guidelines on the following topics:
  • Use of Vital Pulp Therapies in Primary Teeth (revision)
  • Permanent Tooth Vital Pulp Therapy in Children and Ado- lescents
  • Behavior Guidance for Pediatric Dental Patients
  • Frenectomy/Frenotomy and Lactation
The members of the workgroup on Clinical Practice Guidelines for Permanent Tooth Vital Pulp Therapy in Children and Adoles- cents has met monthly since July 2020. It has made significant progress in choosing MeSH terms, developing PICO questions, submitting a Systematic Review and Meta-analysis Protocol to PROSPERO, and conducting extensive literature reviews.
 
The Behavior Guidance Guideline Workgroup is expecting the publication of the Cochrane systematic review on "non- pharmacological interventions for managing dental anxiety in children" in 2021, which will be evaluated and appraised by the workgroup for the development of clinical guidelines. To answer clinical questions within behavior guidance that are not informed by high-quality systematic reviews, the workgroup has proposed the development of a second document of Consensus-Based Practice Recommendations using a Modified Delphi Process methodology.
 
The AAPD Board of Trustees approved the proposal of the EBD Committee to consider the addition of a layperson (such as a parent of a patient or a consumer/health/child advocate) to EBD guideline workgroups when deemed beneficial and rel- evant to the topic of the clinical guideline. By viewing a clinical guideline topic from a different lens, a lay member can bring an insightful and valuable perspective to the workgroup as a whole.
 
Safety Committee Update
 
The Safety Committee continues to monitor the develop- ment of information affecting dental practice safety dur- ing the COVID-19 pandemic. To bring members the latest resources and to help practices succeed safely, the Committee has published the newest resources in "Beyond Re-emer- gence: Pediatric Dentistry Checklist." Beyond Re-emergence now includes short descriptions of each resource, so viewers can read descriptions of the various resources and articles before committing to open each document. Pediatric den- tists needn’t stop their safety journey there; members can also find relevant and useful materials in the AAPD Safety Toolkit.
 
Anesthesia Accreditation. The AAPD and American As- sociation for Accreditation of Ambulatory Surgery Facilities (AAAASF) have partnered to offer a voluntary sedation/general anesthesia accreditation model for pediatric dental practices. This program is in response to the commitment by pediatric dentists to continue to provide safe environments in which to treat children, and is designed for practices in- terested in demonstrating that commitment to their patient families. To learn more about the pediatric dentistry accredi- tation program, please visit https://www.aaaasf.org/pro- grams/outpatient-programs/outpatient-pediatric-dentistry/.
 
Dental Anesthesia Incident Reporting System (DAIRS). The AAPD has collaborated with the American Association of Oral and Maxillofacial Surgeons (AAOMS) in support of the DAIRS data collection system for anonymous reporting of anesthesia incidents. The DAIRS database launched this fall on the AAOMS website with the goal of identifying and cor- recting system-related issues that unintentionally promote anesthesia incidents.
 
N95’s and Respirators…Are You Compliant?
by Joe Castellano, D.D.S.
 
2020 and COVID-19 brought changes to the way we use PPE in our practices and clinics. What we wear, how we wear it, how we put it on and take it off have all been affected. Masks and respirators definitely fall into this category with some stringent guidelines attached to them. The CDC, OSHA, and the ADA all have put forth guidance on what we should use to cover our faces during the pandemic. But what are those recommendations? What does the CDC recommend? What does OSHA require to be "compliant"? What documentation is required? These are all important questions that many of us may or may not know the answer to. What follows is a review of some key points on respirator use in the workplace to help clarify what is required to maintain compliance.
 
As stated in the General Duty Clause of the Occupational Safety and Health Act of 1970, the Occupational Safety and Health Administration (OSHA) requires that "each employer shall furnish to each of their employees employment and a place of employment which are free from recognized haz- ards that are causing or are likely to cause death or serious physical harm to his employees."1 Basically, we are required to protect our employees from risk of illness or injury in the workplace. The use of environmental controls, administra- tive controls and personal protective equipment (PPE) helps employers achieve this safe work environment.
 
One of the key pieces of PPE we use in the dental setting to create a safe environment is the use of a face mask or respira- tor. Currently, CDC guidelines recommend that an N95 mask or better be used during aerosolized procedures. They state, "During aerosol generating procedures DHCP should use an N95 respirator or a respirator that offers an equivalent or higher level of protection such as other disposable filtering facepiece respirators, powered air-purifying respirators (PAPRS) or elastomeric respirators."2 Up until the COVID-19 pandemic occurred, we used an appropriate level face mask for the task that was being accomplished, but due to the need for increased protection from the SARS-CoV-2 virus, a higher level of respirator has been required. Although many practitioners had difficulty securing these types of respirators at the beginning of the pandemic, thankfully as of late, N95 or its equivalent have been more widely available for use in the dental setting.
 
The CDC also states that the respirators should be used in conjunction with a comprehensive respiratory control pro- gram. Respiratory Control Programs must be in accordance with the OSHA’s Respiratory Protection standard- 29 CF 1910.134.2 This standard requires "the employer to develop and implement a written respiratory protection program with required worksite-specific procedures and elements for required respirator use. The program must be administered by a suitably trained program administrator."3 Some of the elements required in a plan include procedures for selection respirators, medical evaluations for those required to use respirators, fit testing of respirators, procedures for proper use, cleaning disinfection and storage of respirators, and training of employees on the proper use of the respirators.3 (The standard contains many more requirements so please refer to it when deciding to create a Respiratory Protection Program for your workplace.)
 
Fit testing is another requirement of the OSHA Respiratory Protection standard when using a tight-fitting facepiece or other respirators. A "Tight Fitting Facepiece" (TFF) is a respira- tory inlet covering that forms a complete seal with the face.
 
The N95 respirator is considered a TFF. The standard states that the employer needs to make sure that employees using a TTF pass a qualitative fit test (QLFT) or quantitative fit test (QNFT) and be fit tested before initial use of the respirator, whenever a different respirator (size, style, model or make) is used, and then annually thereafter.3 There are different companies that can do fit testing. You will need to search your local area to find one that can do the testing required. Most of the testers that I found were testing for industry and not necessarily dedicated to healthcare. Remember when selecting someone to do the fit testing, it is important to make sure that they follow an OSHA- accepted QLFT or QNFT protocol.
 
Medical evaluations of employees using respirators, including TTF’s, are needed as part of the Respiratory Protection Plan.4 According to the standard a medical evaluation needs to be done by a physician or other licensed health care professional using the medical questionnaire referenced by the standard’s appendix C4, or another questionnaire that obtains the same information. A copy should be kept in the employee’s file.
 
A "compliant" respiratory protection program is a detailed document. It is important to use the OSHA’s Respiratory Protec- tion standard when developing a program for your workplace to ensure that all the requirements are met. There are also com- panies that can help you develop a plan. The important thing is to have one in place. Inspections have taken place across the country and there have been employers (yes dentists) that have received fines for not having a Respiratory Protection Plan and/or not being in compliance.
 
N95 face masks, or their equivalent, have become common place in the dental workplace. As we continue to adapt to their use, the wearer should be aware of the potential physiological impact and the potential for increase in blood CO2 levels when wearing them. The literature seems to indicate that there are no severe adverse effects from long term use. There are, how- ever, known physiological effects from extended use of the res- pirators. These include headache, lightheadedness, increased breathing frequency, increased work of breathing, rash, acne, skin breakdown, and impaired cognition.5,6,7 It is important to be able to recognize symptoms if they occur. In most cases, taking a break and removing the respirator, staying hydrated, and practicing good skin care are effective ways to manage the symptoms if they do occur.7 Of course, if symptoms are severe, consult your physician.
 
Respirators have proved effective in the dental setting, espe- cially during the COVID-19 pandemic. Continued diligence is important as we navigate our way through 2021. Making sure you understand the use of respirators and the compliance that is needed with their use is imperative. The AAPD Safety Com- mittee is committed to being a membership resource to ensure we all keep our workplaces, employees and patients safe.
 
All the best in 2021!
 
Resources
Understanding Compliance with OSHA’s Respiratory Protection Standard During the Coronavirus Disease 2019 (COVID-19) Pandemic: https://www.osha.gov/sites/default/files/respiratory- protection-covid19-compliance.pdf
Q&A: OSHA Guidance for Dental Workplaces: https://success. ada.org/~/media/CPS/Files/COVID/QA_OSHA_Guidance_for_ Dental_Workplaces
Dental Compliance: http://dentalcompliance.com/
Respiratory Protection Program: https://www.cda.org/Home/ Practice/Back-to-Practice/Preparing-your-Practice/respiratory- protection-program
 
References
1. OSH Act of 1970. Occupational Safety and Health Administration. https://www.osha.gov/laws-regs/oshact/section5-duties Ac- cessed Jan. 06, 2021.
2. Guidance for Dental Settings: Interim Infection Prevention and Control Guidance for Dental Settings During the Coronavirus Disease 2019 (COVID-19) Pandemic: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html Accessed 01-06-2021
3. Occupational Safety and Health Standards. Personal Protective Equipment. 1910.134 Respiratory Protection. https://www.osha. gov/laws-regs/regulations/standardnumber/1910/1910.134 Accessed 01-06-2021
4. Occupational Safety and Health Standards. Personal Protective Equipment. 1910.134 App C. OSHA Respirator Medical Evaluation Questionnaire (Mandatory).https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134AppC Accesses 01-06- 2021
5. Rebmann T, Carrico R. Physiological and other effects and compliance with long-term respirator use among medical intensive care unit nurses. Am J Infect Control. 2013 Dec;41(12):1218-23.
6. Physiological Burden of Prolonged PPE use on Healthcare Workers during Long Shifts. https://blogs.cdc.gov/niosh-science- blog/2020/06/10/ppe-burden/ Accessed 01-06-2021.
7. Rosner J.Adverse Effects of Prolonged Mask Use among Healthcare Professionals during Covid-19. J Infect Dis Epidemiol 2020,6:130. https://pdfs.semanticscholar.org/bdea/3aef30775ad4505dc7a7c19e9b41ff89baef.pdf Accessed 01-06-2021.

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