Rising to the Challenge: Dental Schools Join the Fight Against COVID-19
By LaShell Stratton-Childers, ADEA Senior Editor
When the COVID-19 arrived in the United States in early 2020, burning a path down the East and West Coasts and eventually across the rest of the country, it quickly became an “all-hands-on-deck” scenario at many U.S. hospitals. Emergency rooms were flooded in some areas. Hospital beds were filling up, and patients were dying at an alarming rate. There were harrowing tales of shortages of personal protective equipment (PPE), nasal swabs, COVID-19 tests and ventilators, putting the welfare of not only patients, but also frontline health care professionals, at risk.
Like most academic institutions, many dental schools abruptly ended in-person classes, either shutting down entirely or shifting to virtual learning only, leaving clinics empty and faculty, residents, fellows and students with much more time on their hands. Several used that time to help in the high-stakes battle against COVID-19.
Dr. Thomas Greany (right) at the CU SDM celebrates the development of a 12-person ventilator that he created at the behest of his former college roommate, Dr. William Whetstone (left), a Professor of Emergency Medicine at UCSF. (Photo courtesy of Thomas Greany.)
Thomas J. Greany, D.D.S., Assistant Clinical Professor in the Department of Restorative Dentistry and Director of Academic Technology Initiatives at the University of Colorado School of Dental Medicine (CU SDM), was recruited to join the fight when he was approached by his former college roommate, William Whetstone, M.D., a University of California, San Francisco (UCSF) Professor of Emergency Medicine, to develop the 12-person ventilator that Dr. Greany would coin the “Mother of All RespiratorY” device, or MARY.
Dr. Greany said that Dr. Whetstone approached him not just because of his aerospace engineering background, but also because—like many American emergency rooms when the pandemic first hit—things were looking “pretty grim” in the UCSF Emergency Department. He said Dr. Whetstone told him about the nationwide ventilator shortages and that “‘patients are dying on the ER floor in Europe and now New York.’”
“It was a pretty compelling call for help,” Dr. Greany said. “He thought I would be a person who may be able to—more or less—drop everything and try to help solve the problem. It was the first few days of the COVID shutdown at CU, so I was indeed able to get to work on it right away.”
Jeffrey James, M.D., D.D.S., FACS, FAACS, Associate Professor and Program Director of Oral and Maxillofacial Surgery and Director of The Cleft and Craniofacial Clinic at Dental College of Georgia at Augusta University (DCG at Augusta), and his team of residents, also responded to the national call for help. He admitted he was initially intimidated when they were tasked with printing 300 nasal swabs a day on the 3D printers in their dental labs, but the pressure he felt only intensified when the governor’s office got involved.
“As my team and I were struggling to meet the task of 300 swabs per day, I was called into a meeting with the hospital leadership, representatives of the Governor, the general in command of the Reserves for the state and others,” Dr. James said. “The CMO, Dr. Philip Coule, looked at me and asked how many swabs I could produce.”
Dr. Jeffrey James at DCG at Augusta and his team of residents printed nearly 7,000 custom-designed nasal swabs per day on 3D printers in their dental labs in response to the COVID-19 crisis. (Photo courtesy of Dental College of Georgia at Augusta University.)
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Dr. James said he was about to tell him they were almost on their way to reaching their goal of 300 a day to satisfy the Medical Center’s needs, but “before I could finish the statement, he interrupted me and said, ‘5,000 … can you make 5,000 per day?’ Silence. The only thought going through my mind was, ‘We are [oral and maxillofacial surgeons]. We don’t fail.’ I looked at him in the eyes and could see the desperation and need. Somehow with a straight face, I replied, ‘No problem.’”
The Battle Starts at Home
For many dental schools, efforts to combat COVID-19 started on their own campuses. When the doors reopened for classes in the summer and fall, most dental schools had implemented significant changes inside dental clinics and had taken didactic lessons from the classroom environment to virtual platforms to ensure the safety of students, faculty and staff.
In addition to training faculty during the summer on how to move traditional classroom lectures online and bringing in staff to help post videos and lectures for remote learning, the University of Saskatchewan College of Dentistry (U of S COD) significantly changed how it operates its dental education clinic and free clinic. Associate Academic Dean Walter Siqueira, Ph.D., D.D.S., said to minimize the time students and patients spend onsite and the likelihood of COVID-19 transmission, the college compressed clinic hours.
“We created one single session that was from 8:30 in the morning to 2:30 where the students are allowed to have two 15-minute breaks between patients for the bathroom or a quick snack,” Dr. Siqueira said. “The students don’t need to stay here for lunch. … The first week it was a little busy, but now its working fine, and the students are each able to see two to three patients a day.”
Dr. Siqueira said the other big change that U of S COD implemented in its clinics to accommodate Saskatchewan dental COVID-19 regulations was to limit aerosol-generating procedures to specific rooms. After a student is finished with a procedure, the room is quarantined for 15 minutes and one of the dental assistants (the college also has a dental assisting program) uses a fog machine that contains Clorox to sanitize the room and equipment.
As an added safety measure, U of S COD intensified its use of teledentistry. Now when students confirm patient clinic appointments, they complete the COVID-19 screening protocols and collect medical and dental history over the phone. As a bonus, the use of teledentistry allows students 20 to 30 minutes more time for clinical experience that would usually be lost to patients answering these questions in person, he said.
The college has also designated certain clinic and free clinic staff as infection prevention control (IPC) officers. Dr. Siqueira said these officers are responsible for ensuring all students follow IPC protocols, including coming early to disinfect their dental units; wearing all the necessary PPEs, such as surgical masks, scrubs and face shields; and following proper decontamination procedures.
Dr. Siqueira said the college is serious about enforcement, even suspending students when they do not follow protocols in some instances. “I am working together with the students for them to understand that I am not punishing them, but educating them, and it is important for us to maintain the College of Dentistry COVID-19 free,” he said.
Meanwhile, research in Canada from the Alberta Federation of Labour shows dentistry is one of the professions with the highest risk of contracting COVID-19, with dental hygienists and dental therapists facing the most risk within the health profession. So, it was no surprise that at Owens Community College in Ohio, the administration shut down its dental hygiene clinic in March for the safety of faculty and students. The college reopened it in June after following Centers for Disease Control and Prevention and American Dental Hygienists Association (ADHA) guidelines, said Dental Hygiene Department Chair Beth Tronolone, B.S., MOL.
“Our reception area is very small, so we put our waiting area into the hallway and put our seats six feet apart with little footprints so they would stay there,” she said. The school also has fewer students/smaller classes and is no longer doing aerosol-generating procedures in open clinic, Prof. Tronolone said.
“We do have KN95 masks, but we have not been using them,” she explained. “We’ve been using a Level III [mask] just because we’re not doing any aerosols at this time. We’re hopefully going to rebuild an area so we can have ultrasonics in an enclosed area, but right now students are only doing ultrasonics on manikins.”
“As far as the PPE for the students, PPE has stayed pretty much the same with the exception of an addition of a face shield that is now mandatory. It was optional before,” said Susan Nichols, RDH, EFDA, B.I.S., dental hygiene instructor at Owens Community College.
In addition to the face shield, students now have to wear head coverings as well, but it turned out to be a new protocol the students like.
“You don’t have to match your scrubs,” Prof. Nichols said. “You can get just a fun print. For them, they feel like they can individualize themselves.”
Like Owens Community College, the University at Buffalo School of Dental Medicine (UB SDM) also made changes to how it operates its dental clinic offerings in response to he pandemic, particularly in its mobile dental unit (MDU), the S-Miles to Go dental van, which has provided no-cost dental care to people of all ages in Western New York for almost 15 years.
“The MDU addressed 185 dental emergencies during the height of the pandemic from March to June 2020,” said Paula Fischer, RDH, Director of School-Based Health Programs at UB SDM. “Currently, the MDU is providing dental care on the east side of Buffalo, a dental health professional shortage area.”
But to continue operation and for the safety of patients, faculty, staff and students, some adjustments were made. “The MDU is equipped with three dental chairs, however, due to health and safety precautions related to COVID-19, only two chairs are currently being used,” Prof. Fischer explained. “In addition, appointment times have been extended and staggered to limit the number of people on the MDU at any one time.”
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These changes are a byproduct of the school’s COVID-19 Task Force created “to address necessary modifications needed to provide dental care in a safe manner, and they have done a terrific job,” she said. In addition to removing chairs for social distancing, Prof. Fischer said, based on the Task Force’s recommendations, they are also limiting the number of people who can accompany a patient in the MDU and decreasing the number of dental students participating in a rotation. Additionally, patients and staff must complete a COVID-19 screening form as well as undergo temperature checks prior to treatment.
Necessity Remains the Mother of Invention
The pandemic has not only required dental school faculty and students to react to new challenges and an ever-evolving landscape, but also be proactive and use their problem-solving skills.
UB SDM students, under the guidance of Dr. Praveen R. Arany, used 3D printers to supply UB students and Western New York dentists with masks, face shields and comfort bands to combat supply shortages due to COVID-19. (Photo courtesy of Philip Sales.)
Under the guidance of Praveen R. Arany D.D.S., Ph.D., Assistant Professor of Oral Biology and Biomedical Engineering at UB SDM, students used 3D printers to supply UB and Western New York dentists with “BE masks,” face shields and comfort bands as safety precautions against COVID-19. The dental school’s lab previously used these printers to create and investigate medication-filled, 3D-printed dentures, smart fillings and bone regenerative scaffolds, but the lab had ceased production due to the pandemic.
Dr. Arany said when the pandemic hit in February, the lab began printing Montana N95 masks instead, led by Jaewon Kim, a periodontics resident; Philip Sales, a graduate student; and Jacob Graca, a third-year dental student. This then led to the development of the BE Mask, a 3D-printable, reusable mask with replaceable filter inserts. Derived from the Montana Mask, the BE Mask incorporates improvements to materials, fit, assembly process, seal, structure, sizing and filter cartridge design, according to UB SDM website.
Their team then began to explore other 3D-printed products that were particularly relevant to dental personnel, Dr. Arany said. That is when, led by Sales, they began to print comfort bands to improve regular mask compliance and face shields for general use.
Dr. Arany said as word of its 3D printing initiative got out, the school received a lot of interest from alumni. “There was also interest from several other dental schools and dental personnel and health care workers from various states, including Texas and South Carolina, among others,” he said.
As of late September, the UB SDM 3D printing team had served more than 530 clients. “There was a significant spike—258 orders—in our dental school student users following reopening in August,” Dr. Arany said. “Several of these item orders include multiple units for their colleagues, staff and personal use. From our last estimate, over 95% of our clinical students (third and fourth years) and several faculty-staff at our school are using our shields, while the recent preclinical students (first and second years) have been ordering these as they begin to purchase/use their loupes in preclinical labs. Moreover, we will be shortly organizing a Buffalo outreach event downtown for our local community. Overall, we have delivered over 1,000 face shields and 1,000 comfort bands to date free of charge.”
As states like Georgia looked to expand testing, one of the major concerns is a shortage of nasopharyngeal swabs. DCG at Augusta produced a 3D printed model to fill the shortage, using a design created by the University of South Florida. (Photo courtesy of Dental College of Georgia at Augusta University.)
DCG at Augusta also used its 3D printers to print facemasks at the start of the outbreak. (The printers had formerly been employed to print dental implants and models of skulls for craniofacial surgery.) But the college eventually made the switch to printing nasal swabs for statewide testing.
“The problem with the facemask was there was no way to validate and test its effectiveness to be equivalent to an N95 with the resources we have,” said Dr. James at the DCG at Augusta. “Sure, we could print it and it looked cool, but there was no way I was going to condone my residents and students using it in a COVID environment without scientifically proving it equal to the N95.”
DCG at Augusta eventually made the switch to printing swabs when the national shortage was publicized. They used a .stl file for a nasal swab from the University of South Florida with some modifications.
“I made the swab smaller so it wouldn’t hurt as much. I increased the length of the tip, so we had more surface area to capture specimen than the original,” Dr. James said. “I also made depth gauges, so the nurses and swabber knew how deep to stick it in the patient’s nose. After I re-presented my design, everyone loved it. We put it to action and saved our health system from a supply chain crisis.”
Though the initial goal was 300 swabs per day, the final production rate was near 7,000 swabs per day, with the team delivering 70,000 swabs in a matter of weeks during the peak of the crisis.
At CU SDM, Dr. Greany said that the MARY device, a field backup ventilator that can support 12 patients at once, also proved to be a success. It is currently being used at UCSF in its Field Hospital set up for treating COVID-19 overflow.
He said with the support of Dan Wilson, D.D.S., his department chair, and Dean Denise Kassebaum, D.D.S., he was able to develop a protype in two weeks.
“I can hardly believe that myself. But it’s true,” Dr. Greany said. “Divinely inspired.”
To build the prototype, Dr. Greany used many components found at a hardware store and a high flow, commercial aquarium pump, which allowed for a continuous flow of air. According to an April 17 CU SDM press release, Dr. Greany “realized that other types of emergency ventilators known as bag-style vents have between one- and three-seconds delay for patients to exhale, but if a continuous flow system was used then, additional patients could be hooked up to the device.”
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He is now working with a local contractor, RK Mission Critical, and has since produced another half dozen units. “Working with their engineering manager, Dwayne Kessinger, we introduced more sophisticated programmable logic controls, solid state electronics and a few other upgrades,” Dr. Greany said. Currently, the device does not have U.S. Food and Drug Administration (FDA) approval, but he noted that RK Mission Critical, in cooperation with the University of Colorado Anschutz Medical Center, is “pursuing a grant to continue the development for military and developing world applications, and FDA certification will be part of the scope of that process.”
Researching Possible Solutions
Innovation at dental schools in response to the pandemic is not limited to resources such as PPEs, nasal swabs and ventilators. Some have taken a more empirical approach. Many schools are conducting research and collecting data, using these important tools to help combat the spread of the disease.
For example, researchers at NYU College of Dentistry (NYU Dentistry) developed a mobile app that can help clinicians determine which patients with COVID-19 are likely to have severe cases. It uses artificial intelligence to assess risk factors and key biomarkers from blood tests, producing a COVID-19 “severity score.”
“Identifying and monitoring those at risk for severe cases could help hospitals prioritize care and allocate resources like ICU beds and ventilators. Likewise, knowing who is at low risk for complications could help reduce hospital admissions while these patients are safely managed at home,” said in a June 6 press release John T. McDevitt, Ph.D., Professor of Biomaterials at NYU Dentistry and Professor of Chemical and Molecular Engineering at NYU Tandon School of Engineering, who led the research. “We want doctors to have both the information they need and the infrastructure required to save lives. COVID-19 has challenged both of these key areas.”
Meanwhile at U of S COD, Dr. Siqueira’s expertise in saliva helped land grants totaling almost $1.3 million from the Canadian Institutes of Health Research for two COVID-19 related projects. The first project is evaluating the incidence of COVID-19 in the Canadian dental offices and among dentists by conducting surveys of 700 dentists and collecting saliva samples from 250 dentists monthly.
Dr. Siqueira’s team at U of S COD, along with researchers at McGill University, are testing the samples for COVID-19 and reporting the results to dentists. The data will also be posted to the college’s website every month “so that people can get informed and this can help the dental regulators to create the guidelines in terms of infection prevention control,” Dr. Siqueira said.
The second project is to create a point-of-care device for rapid testing of COVID-19 using saliva. The research team has “identified six biomarkers in saliva in SARS-COV-2 that could be a biomarker for a COVID device. In our technology now, if you give me the saliva, I can run it in my lab and get the results for you in one and half hours and tell you if you are positive or negative.”
Dr. Siqueira said the hope is they will have the first prototype by January 2021, samples can be self-collected, and result times can be reduced to a half hour to an hour, at most.
A Lesson in Giving Back
Dr. Greany said he hopes that his dental school students take away from his invention of the MARY device that “education is never wasted. That we’re called to serve others, especially in time of great need. That there are wonderful people in this world who are willing to roll up their sleeves and work alongside a worthy cause. Dentistry is frequently a poster child for such efforts, and also that desperate times can inspire us all to not only survive, but improve the world around us.”
When it comes to DCG at Augusta’s massive ramp up of 3D-printed nasal swabs, Dr. James said, “I would like to think we helped the university improve their relationship with the community. But in all honesty, maybe we just did what was expected of us. Our community probably looks to [DCG at Augusta] for answers in tough times like these. I think we all stepped up and met that expectation.”
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