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COVID-19 and Inequities in Oral Health Care for Older People: An Opportunity for
Emerging Paradigms

Article  in  JDR Clinical & Translational Research · June 2020

DOI: 10.1177/2380084420934742

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 JCTXXX10.1177/2380084420934742JDR Clinical & Translational ResearchShort Title
research-article2020
Vol. XX • Issue X
Special Communication
COVID-19 and Inequities in Oral
Health Care for Older People: An
Opportunity for Emerging Paradigms
S. León1,2 and R.A. Giacaman1,2
Abstract: Severe restrictions have
been imposed in most countries
for oral health care to the general
population, allowing treatment only for
emergencies, because of the generation
of aerosols during clinical procedures
and to ration personal protective
equipment (PPE) during the pandemic.
This article stresses the critical
situation that affects oral health for
older persons in the complex times of
the COVID-19 pandemic. Older adults
are at high risk for the viral infection,
but neglected dental conditions
may worsen their health, triggering
infections that can lead to local and
systemic complications, compromising
general health. We propose that under
current and possibly future scenarios,
teledentistry and the minimal
intervention dentistry approach
may play a pivotal role in reshaping
the profession. The already existent
inequities in oral health care may
be exacerbated due to the pandemic,
especially in the developing world.
More research along with a strong
educational component in the dental
curriculum must be emphasized.
DOI: 10.1177/2380084420934742. 1Gerodontology and Cariology Unit, Department of Oral Rehabilitation, Faculty of Health Sciences, University of Talca, Talca, Maule,
Chile; 2Chilean Society for Geriatric Dentistry, Chile. Corresponding author: R.A. Giacaman, Gerodontology and Cariology Unit, Department of Oral Rehabilitation, Faculty of
Health Sciences, University of Talca, 1 Poniente 1141, Talca, Maule 3460000, Chile. Email: giacaman@utalca.cl
© International & American Associations for Dental Research 2020
COVID-19 and Inequities in Oral Health Care
COVID-19 may be an opportunity to
change canonical paradigms. The
dental profession must reflect and take
action to face future challenges.
Knowledge Transfer Statement: This
article provides an overview of the oral
health situation imposed by COVID-
19 and the minimal intervention
alternatives to provide care to older
people who are at risk and have
reduced access to care.
Keywords: older adults, elderly, Latin
America, pandemic, teledentistry,
minimal intervention dentistry
Dental Care Restrictions
The health crisis imposed by the
COVID-19 pandemic is taxing public
health systems worldwide, many
of which are on the verge of their
capabilities. Due to the rapid spread of
COVID-19, many countries have taken
measures to restrict human mobility
(Kraemer et al. 2020). Dental practice
presumably imposes a high risk of
spreading the infection. Although
alternate routes are under study, the
most likely mechanism for COVID-
19 transmission is direct or indirect
contact with droplets from the airways
and respiratory secretions of infected
people. Dental care, in the context of
the pandemic, poses a potential risk of
infection due to the proximity of the
patient’s airway to dental personnel
and the generation of aerosols
during clinical procedures. Thus, oral
health service providers have had to
postpone elective care, except for cases
considered to be dental emergencies
or life-threatening conditions. These
restrictive measures also seek to
ration the use of personal protective
equipment (PPE) during the pandemic,
in accordance with recommendations
made by the Centers for Disease Control
and Prevention (CDC) (Dave et al.
2020).
In the coming months, in addition
to containing the current pandemic,
health systems will face an avalanche
of patients whose health has been
compromised due to untreated chronic
diseases, including oral conditions such
as periodontal diseases and dental caries,
currently considered noncommunicable
1
 JDR Clinical & Translational Research
diseases. Furthermore, increasingly
robust evidence has demonstrated the
association of oral health and systemic
conditions. Oral diseases can trigger
inflammatory and infectious processes
at the systemic level that complicate
the condition of patients with chronic
diseases, which will exacerbate the
already bleak outlook for the health
system globally. It is known that older
people are the highest risk group
within the COVID-19 pandemic,
attributable in large part to the high
prevalence of chronic diseases and
the weakening of the immune system
due to immunosenescence. The risk
is increased in older adults who use
angiotensin-converting enzyme (ACE)
and angiotensin receptor blocker (ARB)
inhibitors for heart conditions, because
both drugs upregulate ACE2 receptors,
which are the receptors used by SARS-
CoV-2 to enter type II alveolar cells
in the lungs. Hence, the scarce data
available indicate that advanced age
and comorbidities put older adults at
the highest risk for mortality if they
become infected with COVID-19.
Thus, in addition to the already poor
oral health of the elderly population,
which entails high prevalence rates of
caries, advanced periodontal disease,
tooth loss, dry mouth, and oral
cancer, the lack of access to medical
management of chronic diseases is
expected to further deteriorate oral
and systemic health. The need for
additional PPE during procedures
poses other challenges to dental care,
because the use of this equipment may
jeopardize communication, closeness,
and compliance in patients who
have cognitive impairment, physical
impairment, or dementia. For example,
older persons with hearing impairment
will find it more difficult to understand a
dentist who uses PPE.
Inequities and Access to Oral
Health for Older Persons
In the developing world, particularly
in Latin America, there is evidence of
large inequities in access and use of
2
dental services among social, ethnic,
and economic groups, greatly affecting
older persons (León et al. 2018). These
inequities, added to the current situation
imposed by the COVID-19 pandemic,
will become even more critical for
older people residing in long-term care
institutions. Older persons should be
isolated to prevent infection with the
virus, but long-term care institutions
are often overcrowded and the
caregivers and personnel receive little
or no instruction regarding prevention
of virus transmission. Caregivers in
these institutions are typically poorly
educated and/or poorly trained, live
in multigenerational homes, and use
public transportation. All of these factors
increase the likelihood that caregivers
will bring COVID-19 infection into
long-term care institutions, increasing
infections and deaths among the patient
population. It is expected, therefore,
that the general and oral health of these
elderly people will be even poorer than
before the pandemic.
Restrictions in access to oral health care
due to the COVID-19 pandemic will add
to the already existent barriers for older
people, especially those with cognitive or
functional impairment living in long-term
residences. The expected consequences
of the lack of dental care will worsen
oral conditions, imposing a new burden
for the scarce dentists who specialize in
geriatric dentistry, underlining the need
for training in this area.
Minimal Intervention Dentistry
as a Strategy for Oral Health
of Older People during
COVID-19 and Beyond
The worldwide crisis generated by the
pandemic offers a unique opportunity
to reshape the canonical approach, not
only for restorative dentistry, but for
the entire dental profession. Confined
and institutionalized older persons,
especially those with mild to severe
cognitive impairment or dementia,
cannot receive conventional dental care.
Reduced mobility excludes older adults
from being treated in a conventional
Month 2020
dental clinic. Two strategies emerge as
potential solutions to deliver dental care
to older adults during the COVID-19
pandemic and in the future: teledentistry
(Alabdullah and Daniel 2018) and
minimal intervention dentistry (MID)
(Innes et al. 2019).
Teledentistry allows remote counseling
to people who cannot attend a dental
clinic or other health care facility. With
the increasing and extended use of
cell phones and computers and more
affordable access to the Internet, people
living under strict confinement or in
remote and rural areas can be assisted
by a dentist via teledentistry. Even before
the current crisis, oral health care for
older persons in Latin America was
subject to inequities. Using a simple
technology, such a digital photograph,
chat, or text message, teledentistry can
lessen the inequities in oral health care,
granting access to care for millions who
cannot be seen by a dentist. Despite the
advantages of using teledentistry, triage
can be challenging when treating older
persons with cognitive impairment or
dementia. Pain could be underreported,
and interaction with caregivers will be
crucial to identify facial swelling, broken
teeth, or changes in eating patterns.
Teledentistry can be used to deliver a
wide range of measures to improve oral
health without the need for physical
attendance. Some of the possibilities
offered by routine teledentistry
include nutritional counseling, salivary
stimulation, prescription of fluoridated
toothpastes for preventive or therapeutic
purposes, and simple hygiene
instructions to residence caregivers or
staff to decrease bacterial load and the
resultant risk of aspiration pneumonia in
the severely dependent population.
On the other hand, MID is a
philosophy in dentistry that goes beyond
the scope of restorative dentistry. MID
aims to preserve what we have called
the “biological asset,” meaning the
preservation of sound and functional
oral structures throughout the life course.
Embracing the MID philosophy will
avoid the restorative cycle, whereby
early small restorations are continuously
 Vol. XX • Issue X
replaced by increasingly larger
restorations, leading to tooth and tissue
loss. The preservation of oral function
and the biological asset throughout the
life course should be the overall goal for
the dental profession.
Given the restrictions to conventional
dental care during the COVID-19
pandemic and potentially after the
pandemic or even during the emergence
of new viruses threatening the world,
MID can become the new standard of
care, at least for institutionalized and
dependent older adults. In restorative
dentistry, techniques under the umbrella
of MID do not generate the virus-
spreading aerosols, thus allowing dental
care with minimal risk of contagion,
following most international guidelines.
Manual techniques or the use of low-
speed rotatory instruments for carious
tissue removal, such as Atraumatic
Restorative Treatment (ART) or the partial
or selective removal of carious tissues,
can be promoted and implemented, even
within older people’s houses and care
residences. Available evidence supports
self-administered and noninvasive
approaches to treat caries lesions in
older adults through the use of high-
fluoride toothpaste, which has become
the treatment of choice in clinical
guidelines such as those by the American
Dental Association. Likewise, periodontal
treatment can be delivered via the
MID approach, through an adequate
maintenance plan, self-care, and tobacco
control, resulting in successful periodontal
healing and regenerative therapies and
lower morbidity.
Besides addressing the obvious
biological factors, modern prevention
and treatment of oral diseases must
entail a more holistic view of people.
Public policy cannot treat older adults
in a standardized way, and protection
measures must be individualized
through a comprehensive assessment
of individual patients: their habits,
traditions, and beliefs in addition to
social, cultural, and educational levels.
The challenges of the COVID-19
pandemic provide an open gate for a new
dentistry that uses different approaches to
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COVID-19 and Inequities in Oral Health Care
provide effective care at lower cost and
higher reach. Likewise, future scenarios
underline the need to reassess dental
training at universities, incorporating the
dentist into the interdisciplinary health
team and reinforcing students’ “soft
skills” and communication competencies
to effectively promote health, induce
behavior change, and halt disease
progression.
Future Challenges and Conclusions
In the context of the COVID-19
pandemic, MID can emerge as a low-
risk strategy to resume dental work in
public and private settings. In addition
to curtailing treatment for patients,
restrictions imposed on dental care
provision have created severe economic
hardship for dentists, dental assistants,
dental hygienists, and the associated
industry. Hence, it is urgent for many
people to return to work and recover
their source of income. The dental
profession and the health system
are facing higher costs due to the
need for additional PPE during every
intervention to control aerosols and
the risk of infection, and the profession
must raise awareness of this problem
among policymakers. Rather than being
considered a second-hand solution for
poor people, teledentistry and MID can
become the new standard of care for
pandemic or postpandemic dentistry,
mainly, but not exclusively, for elderly
populations, including those with
cognitive impairment and dementia.
Although the concept of MID is not
new, the pandemic may offer a window
of opportunity to embrace MID and
extend its use. Developing countries
with reduced expenditures on oral
health for the elderly population can
benefit from the implementation of
teledentistry and MID, which may
become key components in public
health policy to reduce severe inequities
in access to oral health care. The dental
profession must reflect on the current
and subsequent scenarios and plan for
the future, considering the nascent needs
and opportunities that will be created
after these dark times. Great crises hide
great opportunities, and the COVID-19
pandemic must not pass as a disturbing
and painful memory in our lives, but
rather must serve as the landmark for a
new dentistry that ensures oral health
and quality of life for everyone.
Author Contributions
S. León, contributed to conception,
design, data acquisition, analysis, and
interpretation, drafted the manuscript;
R.A. Giacaman, contributed to
conception, design, data analysis,
and interpretation, critically revised
the manuscript. All authors gave final
approval and agree to be accountable for
all aspects of the work.
Acknowledgments
This article was funded by internal
resources of the Department of Oral
Rehabilitation and had no external
funding. The authors declare no potential
conflicts of interest with respect to the
authorship and/or publication of this
article.
ORCID iD
R.A. Giacaman https://orcid.org/
0000-0003-3362-5173
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