18 dentists on practice operations as COVID-19 spikes again

The number of coronavirus cases are surging across the U.S., and dentists are prepared to continue treating patients, but they're concerned about safety and how more missed appointments could affect patient health.

Here, 18 dentists answer this question: How are you thinking about your practice for the next few months as COVID-19 cases increase around the U.S.?

Responses are lightly edited for clarity.

David Keller, DDS, MBA, of Granite Dental (Vancouver, Wash.): Honestly, COVID-19 'surges' don't even hit my radar screen. Our infection control practices have been effective for decades at preventing aerosol and droplet contamination within our offices, from patients to staff, or staff to patients. So completely honestly: no fear.

My biggest concerns center on public fear based on misinformation and oppressive regulations based on knee-jerk or politically motivated protocols. In my state, Washington, dental care was determined to be nonessential. While I don't think the governor will make the same mistake again, many in my state believe the very air we breathe can kill them.

Patients forget and are not being told by the 'experts' on TV that the biggest protective factor against disease is not social distancing or masking, but the efficiency and effectiveness of your personal immune system. The best way to protect yourself from disease is to be healthy: Eat right, get enough sleep, reduce stress, drink enough water, exercise and avoid the things that we know are bad for us — smoking, vaping, alcohol consumption, etc.

Many offices across the nation are reporting increases in both decay, which is largely an localized oral problem, and periodontal disease, which has a massive negative systemic influence. For many of my patients, if the COVID situation has activated or exacerbated their periodontal disease, treating it may be one of the best investments in their health, and therefore their COVID resistance, they can make.

Jeffrey Cummings, DDS, of RestoreTeeth (Waltham, Mass.): I focus on keeping patients safe and providing the best care I can, giving patients the access they need. We are very respectful of COVID-19 and believe confidently in our infection control policies and social- distancing practices in place.

Louis Malcmacher, DDS, of American Academy of Facial Esthetics (South Euclid, Ohio): In our practices and the practices of AAFE members who are dentists, we are looking at the next few months as a time to reevaluate the direction of our offices and the services we offer. AAFE member dentists who offer Botox, dermal fillers and PDO thread injectables have been thriving during this pandemic once their offices reopened. Many dental practices report the aesthetic injectable procedures have been maintaining their production while other dental services are down 20 percent or more.

Kevin Laing, DDS, of Kevin M. Laing, DDS (Van Wert, Ohio): I am obviously concerned about the health and well-being of my patients, but also my dedicated staff. We have always practiced universal precautions to protect everyone from cross-contamination and from airborne and bloodborne pathogens. Hepatitis, HIV, TB and many other diseases are something that we are constantly aware of and take precautions for. So with the additional cautions of prescreening, temperature checks, masking and hand sanitation, I believe that we are in good stead to safely treat most patients.

Financially, the year has been challenging. For so many patients, their prescheduled recheck and hygiene appointments have been adversely affected. It has been a struggle to reshuffle patients back into our schedule. Starting in late September, we were feeling the six month echo of the national shutdown. I expect it to take a couple years to get things sorted out. Senior patients are particularly reluctant to reschedule, and the latest news is again frightening them from seeking care. We have had patients with ongoing periodontal problems really slip into worse condition that will take extra measures to help them overcome [these issues]. Patients that were mid-treatment have required greater prosthetic adjustments and remakes because of delays.

I have faith that we will work through all of these problems. Some practices that I read about have not been as fortunate. New graduates and the near-retirement dentists have shouldered the brunt of the COVID-19 related challenges, and I feel for them.

Jeff Dalin, DDS, of Dalin Dental Associates (St. Louis): We worked very hard on acquiring proper PPE and setting up safe practice protocols before reopening back in May. We are very comfortable with everything we have done, and our patients constantly compliment us on how safe they feel coming to our office. We feel these protocols will keep our office a safe place to work at and visit. We all have to be very careful and vigilant with what we do and who we are around outside of working at our office.

Jonathan Engel, DDS, of Southern California Dental Health Associates (Los Angeles): I believe that the patients' perception of safety will again worsen, and patients won't keep their appointments or make new ones. I feel that it will impact their dental health and overall health, and the outcome is the opposite of what they want. They increase their likelihood of having a more serious or fatal reaction to infection with COVID-19.

Jenn Vitulli, Dental Director of Park56 Dental (New York City): As the number of COVID-19 cases rises again, we continue to operate under the same vigorous safety protocols that we implemented back in June. We prescreen our patients and team members, have an ample stock of personal protective equipment, UVC filters and extra-oral suction units throughout the office. We do not anticipate loosening any of the safety measures that have successfully kept us healthy. With strict travel restrictions in place, there are fewer people in the city, but we have seen a massive uptick in unique visitors and new patients.

What is critical in this post-COVID era is that we must meet our existing patients' demands by offering digital dentistry, virtual visits and same-day care. In doing so, our production numbers are now reaching close to 90 percent or more of our pre-COVID numbers. We have expanded our hours, offer more patient-financing options, and do anything we can to eliminate the stress for our patients, even if that means paying for their parking.

George Karalis, DDS, of Karalis Dental and Implant Restoration (Chicago): My practice and those with which we have collaborative alliances held meetings at the beginning of the pandemic and decided that we needed to institute protocols in anticipation of a surge but also to position our practices to be agile in the face of future pandemics.

We are following stringent protocols which will remain in place and feel we are well prepared to deal with the surge.

The amount of damage that our patients have incurred during this pandemic has been astounding, and we need to sustain our operations to service our patients' needs, while mitigating transmission.

Yahya Mansour DDS, MS, DICOI, FAGD, of Rodeo Dental and Orthodontics (Fort Worth, Texas): As COVID-19 surges again, we are seeing recent history repeat itself. We went through this in the spring, and as a country, we made some mistakes, we learned a ton, and we are now ready to apply it to help keep our staff and patients and loved ones safe. We know what's coming; it's not like we are going to be surprised by this again. So as I think ahead to see how I navigate my company through the next few months, I have to figure out with my team:

  • How do I keep all the employees safe in multiple offices and different regions?
  • How do we keep our patients safe and operating at a high level of safety and quality of care?
  • How do we make sure patients are still coming in for important dental care?

One of the mistakes we made as a country was shutting down dental offices in some form. Now we know that dental health is essential and must continue to function as part of the country's health system. Good oral health equals good overall health, and dentistry has been aerosolizing viruses and dealing with proper infection control for decades. This is no different. We have proved, time and time again, that the dental office is one of the safest places to be, and it is this messaging that needs to be broadcast to our team members and our patients that will help us navigate through this.

As practice owners, we have to prepare for possible and improbable shutdowns, the effects of that on our staff in terms of payroll, HR and benefits. We have to enforce evidence-based systems to prevent intraoffice transmissions such as reduced break rooms, staggered lunches, diligent screening and mask-wearing, along with stringent infection control. We must also empower and encourage our staff on 'out of work behavior.' The major risk point is behavior out of the office and bringing the virus into the office. Now we cannot control behavior in people's personal lives, but we can educate and empower team members to do all they can to help prevent the transmission and build a COVID- free community together by sharing facts, tips and data with our teams in morning huddles, weekly town halls, or any other socially distant meeting. Dispelling, the myths, truths, and proof of COVID-19 is going to be the way forward to keeping us safe, open to treat patients, and healthy.

Chad M. Carpenter, DDS, of Carpenter Dental, Dakota Dental 4 Kids and Rapid City (S.D.) Dental Clinic: My biggest concerns are:

1) Team safety. Four team members and one doctor, we have 31 total in our organization. so far none have been out with positive COVID-19 diagnosis. I worry one of us will get really sick.

2) Overhead. Revenues are down, yet most expenses are the same. We are paying everyone, of course, when they are out, and not forcing anyone home early, even if we have low census.

3) Psychology. The team has been amazing so far, and all five of our doctors have remained upbeat and positive. However, as time and COVID go on, we are running low on energy. We need constant reminders, and we are trying to celebrate wins more to keep morale up. Team is stressed as schools here are closed. It seems like on days we are busier, half the team is out. This has never happened before.

Usually we are pretty strict with showing up to work, but with this pandemic, we have pivoted and are super flexible. This makes it hard at work but has kept morale high.

4) Cancellations and no-shows, which are rare in our practices, have increased, putting strain on the administrative team. This pandemic has made us so thankful we had a strong team culture heading in. The team has pulled together a lot to make it through, but we know we have a long way to go.

Tesa Jolly, DDS, of Family Dentistry: Tesa Jolly (Pulaski, Tenn.): The excitement and hope that comes with a vaccine also is shaded by the fear that dentists will not be able to order necessary supplies to take care of our patients. Almost weekly there is a threat of supply shortage or large price increases for our dental supplies. Lately we have been told needles, anesthetic and gloves will be very hard to find in the near future. More industries are now using PPE and hospital-grade disinfectants, and we have already seen a price increase in those products, if we can even find them at all. Dental supply companies have limited how much you can order of materials. Other dental suppliers won't even allow an order to be placed if you had not been active with them before COVID-19. What really will be in shortage, for how long and how much of a price increase it will take, are constantly on my mind. If I underestimate any of those things, it could be detrimental to the practice.

My employees are having to go on FMLA often due to potential exposure from a spouse or due to lack of child care if schools/day cares close. We are constantly having to juggle the schedule last-minute to accommodate for an absence. I'm very worried that I will have to quarantine at some point and shut my practice down for however long the CDC recommends at that time. With a surge in cases, the chances of coming into contact with the virus are much higher. There is a risk for multiple times that I might have to close my office. When I'm not at my office, it doesn't generate enough money to pay my overhead. Eventually, my emergency funds will run out, and I will have to make some difficult decisions.

My patients are also missing appointments for the same reasons. Awaiting COVID tests, symptoms of COVID, positive for COVID-19, or family member having COVID-19 are reasons that we have several last-minute cancellations. I fear that if cases begin to get worse, patients will put off dental care. I would have to lay off employees for lack of work, and this time there wouldn't be a super-charged unemployment to help make ends meet for them.

Zavash Zarei, DDS, of Zarei DDS (Coralville, Iowa): I have slowed down to no employees, and I'm doing everything myself. The front door is locked, and I sit down between patients. As soon as I find a service to process and check insurance claims and billing, I do not think it will ever go back to the way it was.

Shalom Mehler DMD of Cedar Lane Family Dental (Teaneck, N.J.): I have been preparing by assuming the worst-case scenario. That means having adequate PPE (when available) as well as adequate supplies on hand. I am encouraging patients to come in now, so that if things revert back to the worst-case scenario, such as the case in March, they will not be left with work that is incomplete.

Municipal buildings in my town of Teaneck, N.J., have just been mandated to be closed, and I hear from physician patients of mine that inpatient cases have risen in local hospitals. Work will continue to be slow, as some patients are fearful about coming in, and the new patient flow has slowed. These are challenging times, and all I can hope for is that dental professionals will be considered essential and will not be shut down, even if things get worse. Dentists are infection- control experts, and we know how to keep things as safe as possible in order to allow for us to continue caring for our patients and staff in the safest manner possible.

Ronnie Myers, dean of Touro College of Dental Medicine and professor of dental medicine (New York City): I am encouraged by the recent data published by the ADA in regards to the low infection rates in dental healthcare workers, which mean​s the extraordinary efforts put in place by practicing dentists for infection prevention have been effective. The dental profession has been, and always will be, at the forefront of taking the appropriate precautions in protecting patients above all else. Oral health care is an essential service, and I believe dental offices are positioned well to continue operations, even during the recent surges of cases throughout the country.

Bonnie Bateman, DDS, of Los Altos (Calif.) Dental: I am going to keep working with all the PPEs until the state of California shuts us down.

Charles E. Crowl, DDS, FADIA, of Magnolia Dental (Louisville, Ky.): While patients came back into regular, routine and emergency care after the initial COVID outbreak, there remains a portion of the patient population that is hesitant to seek out care. With the current rising COVID case numbers being reported, this population will likely miss routine or needed care for the foreseeable future. In addition, with the increasing state-mandated restrictions to lifestyle issues, there may be additional restrictions placed again upon healthcare delivery.

Marshall S. Dicker, DMD, TCB Dental Care (Jersey City, N.J.): [We will] keep on with the recommended precautions and ask and suggest patients get screened on an ongoing basis. [We will] offer screening in the office.

Marion Jenkins, PhD, FHIMSS, Partner of HealthSpaces: We're not involved much with dental.On the other hand, we have tons of depth/breadth in the physician practice space, especially helping them deal with strategic technology issues, helping practices eliminate and minimize technology sprawl, such as dealing with all the EMR interfaces and add-ons that plague physician practices, and getting a handle on technology so it aligns with clinical ops. Usually technology runs things, and that's bass-ackwards.

This involves helping physician practices identify and categorize technology priorities and create a long-term strategic technology road map to help deal with all the conflicts involving the constant limitation of time, money and scope.

Rebecca Straight. Dental Hygienist and Sales Rep & Leslie Stevens, CEO, HealthyStart a division of OrthoTain (Winnetka, Ill.): What if I said that COVID-19 presents an opportunity for every dentist to create a more comprehensive type of dentistry that goes beyond just looking at teeth by providing overall healthcare? All of us are looking to prevent disease exposure and increase our immunity. A dentist's expertise in the oral cavity can actually improve a patient's immune system, as well as neurological, endocrine and hormonal functions by identifying the outward symptoms of sleep disordered breathing and its root causes. The ADA, AAO, and the AAPD have all incorporated guidelines to ensure that the dental profession is screening for sleep. The number of patients affected by SDB is staggering. Nine out of 10 children will exhibit one or more outward symptoms representing 40 million children in the U.S alone.

HealthyStart is a comprehensive system that incorporates education for both dental professionals, as well as patients, evaluation tools to identify the outward symptoms of SDB, the ability to customize a patient consultation booklet, and a comprehensive oral appliance treatment and protocol to be implemented in either the dental office or in a teledentistry environment. Treatment is always continuous and is not impacted by any type of COVID-19 shutdowns.

More articles on dental:
ADA won't recommend postponing dental care amid COVID-19 surges
SmileDirectClub partners with MetLife dental insurer
Wisconsin Dental Association welcomes new president

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