If you received an email from your dentist in late March explaining that they will only be available for emergency visits, you are not alone.
This new approach to dental care was not only the result of expansion of social distancing guidelines and efforts to allocate critical resources to frontline providers, but stemmed from a decision by the Centers for Medicare and Medicaid Services (CMS) on March 18 to suspend elective surgeries along with non-essential medical, surgical or dental procedures.
While dental care, and oral health in general, is vital to overall health and well being, the decision to limit visits was especially difficult news for those with complex dental needs, ultimately shifting us to a new normal of dental care in the US.
In the midst of the coronavirus pandemic, this situation was to be expected, especially since the exposure risk to dentists and dental staff would be exceedingly high. In light of this elevated risk, the American Dental Association (ADA) along with the CDC have issued guidelines and instruction regarding safety issues including the importance of screening and personal protective equipment (PPE). Whether dentists can perform rapid point-of-care office-based tests for the virus is an issue which has yet to be settled, especially in light of presymptomatic and asymptomatic transmission of SARS-CoV-2.
Certainly, the importance of PPE for frontline providers in ERs and ICUs made sense as part of the decision to close dental offices last month, part of a plan to assure an adequate supply.
Jenna Smith, RDH of LLM Dental Associates in midtown Manhattan, quickly realized and recognized the priority for PPE for frontline healthcare providers as part of COVID-19. Her own experience provided the rationale for those working on the front lines in ERs and ICUs.
“As a practicing Dental Hygienist for 24 years,” she explained, “the most important rule I learned back in school is using Universal Precautions when treating any and all patients. Dentists and Hygienists are at a very high risk of contracting and spreading infections on a daily basis due to close patient contact, spraying aerosols from dental instruments and coming in direct contact if patient’s blood and saliva.”
“Treating everyone as if infected with a disease is key. By donning the proper PPE and complying with OSHA rules and regulations for sterilization and disinfection, dental personnel can reduce the risk of contracting and spreading disease.” she added.
All this makes Smith especially realistic and knows that simply put, this virus is life and practice-changing for her and her colleagues. “Covid-19 poses a huge challenge for any dental office. We must be recognized as front line workers. Dentists and Hygienists have the highest risk of exposure equal to doctors, nurses and respiratory therapists.”
With this issues in mind, the general consensus is that most patients are reluctant to visit an emergency department for dental needs, but certainly would if there was an emergent concern such as intractable bleeding, swelling or unrelenting pain.
While Teledentistry has enabled dentists to connect with their patients for routine needs (assessment of dental pain, oral lesions, routine monitoring) the bottom line is that not all dentists are equipped to do this, with the added reality a photo or video chat may just not be enough to truly understand and diagnose specific dental conditions. The truth is that technologies such as augmented reality (AR) and virtual reality (VR) may ultimately help in trying to produce a more detailed visual assessment of the oral cavity, but we are just not there, just yet.
Ruben Cohen, DDS, an oral and maxillofacial surgeon affiliated with both Lenox Hill Hospital and Mt Sinai Hospital in Manhattan said that telemedicine has a useful aspect of his practice during COVID-19. “It helps reassure patients and triage who needs to be seen right away, and who can wait,” he offered. Images, assuming they are of reasonable quality, can be valuable is trying to figure out what is going on with a patient, he explained.
Moving forward as we navigate the pandemic, many questions arise about the logistics of opening dental offices again.
One key issue involves testing patients and dentists alike for the virus via testing kits, which the ADA and CDC have just begun to tackle as a rate limiting step in ensuring the safety of the American public.
The availability of testing kits from the Department of Health and Human Services (HHS) for re-opening dental offices was recently reported by The Hill, a issue on the mind of many ADA members and dentists alike.
“When we get back, until such time as there is a vaccine or a reliable treatment, we will have to screen our patients and ourselves daily, said Gabriela N. Lee, DDS, of LLM Dental Associates in midtown Manhattan. “We will probably send a checklist to our patients along with their text and email appointment confirmations. It will ask: Have they have recently travelled, and to where, have they been in proximity to anyone who is ill with fever, any cold or flu-like symptoms, including gastrointestinal flu in the past two weeks, have they experienced any of the above symptoms in the past two weeks.”
“We will ask them to reschedule their appointment if they answer “yes” to any of the questions. We will also have an infrared forehead thermometer to check every patient. And at time of the appointment, we will also verbally confirm that they have read the questions above and can still reply no to all of the questions,” added Lee.
With regards to coronavirus testing, Lee explained that “I personally would love to be able to test myself, my team and my patients for active COVID-19 as well as antibodies to see our status prior to treatment. While it is an ideal venue and would be a big service to our patients and the larger community, we are currently not able to do this.”
Lee stated that the ADA is working with the government to make it possible for “dentists to do this legally and with adequate test materials.”
As things currently stand, dentists are not legally able to administer tests for the coronavirus. This is clearly an important public health matter and could impact members of any dental practice, especially patients who may be infected but remain asymptomatic. ADA President Chad P. Gehani and Executive Director Kathleen T. O’Loughlin sent a letter to HHS on April 17 urging HHS to allow dentists to test patients in their practice.
“Dentistry is essential to the public’s health. Enabling dentists to test patients prior to dental treatment will help lower the ‘very high exposure risk’ of dental personnel in contracting COVID-19 when treating infected but asymptomatic patients,” wrote Gehani and O’Loughlin in the HHS letter. “It would add a layer of safety for both dental personnel and the patients they treat. This is important not only now—when most dentists are performing only urgent and emergency dental procedures—but also as the nation cautiously reopens.”
“The lack of test materials is a big limiting factor,” emphasized Lee. “I personally think that emphasis has to be on creating sufficient quantities of reliable tests and that testing of both types (viral and antibody) should be rolled out as soon as possible using the currently closed schools as sites for testing; the way we do with voting. The buildings are perfect for this, with lots of halls and auditoriums and cafeterias.”
Smith added that the close proximity of dental providers to patients is certainly problematic in the new normal of dentistry. “Reopening the dental office knowing that social distancing is not possible during procedures or dental cleanings poses a threat to our safety and the safety of our patients. We need testing for ourselves and our patients to monitor and prevent spread of this virus,” she offered.
“Working on protocols to prevent those infected from entering the office and receiving treatment need to be in place and implemented prior to dental offices reopening. This includes mandatory COVID-19 testing and results prior to appointments. Taking temperatures and medical/travel histories before a patient can enter the office is paramount. For the staff, obtaining N95 respirator masks, disposable gowns, gloves, limiting and spacing appointments as well as not using aerosol producing equipment such as cavitrons and air polishers is necessary, added Smith.
But Smith explains that “the biggest challenge to date is not having access to testing, and not having the proper PPE available to us at this time,” with the caveat that “most dental offices have donated their PPE supplies to hospitals.”
But the bottom line is that “we need to be recognized as high risk front line workers and get the necessary supplies we need to practice safely.”
While emergency dental care is available at ERs, it would still be preferable to see a dentist in the office setting, assuming one is available.
That said, before a coronavirus vaccine is widely available, dental emergencies can still be accommodated in offices—assuming they are open, and appropriate PPE and universal precautions are followed by dentists and their assistants. (It’s best to check with your dentist).
The issue of testing patients for elective or non-emergent visits remains in flux as we await the decision by HHS regarding allowing dentists to begin testing patients. Additional considerations for opening offices include appropriate social distancing, a limited number of patients in the office, along with office staff wearing appropriate facemasks or facial coverings.
One harsh reality is that lack of PPE may be a factor limiting the opening of dental offices—even for emergency dental visits (and procedures) which have been minimal, in comparison to normal office volumes at this time.
According to reporting today by NPR, Japan will now allow its dentists to begin performing testing for coronavirus using nasal and throat swabs (PCR-based assay). In the past few weeks, the number of confirmed cases has risen, partly the result of increased testing. There are now about 13,600 confirmed cases in Japan, along with 385 deaths. Japan currently is performing about 9,000 PCR tests daily. The impetus for dentists to perform tests was largely a desire to boost testing capacity to up to 20,000 people per day, a goal set by Prime Minister Shinzo Abe.