Dr. Elizabeth Reynolds, in full protective gear, works with a patient. (Photo by Ash Daniel)
Going to the dentist’s office in the age of the COVID-19 pandemic has a very different look and feel than it did just months ago. Everything from check-in to how much protective equipment the dental team wears has changed drastically and will stay that way for the foreseeable future.
When patients first see the dental team clad in full personal protective equipment, it can be intimidating and overwhelming. “Having that much of a layer between you and your patient is what is challenging for us,” says Dr. Elizabeth Reynolds, president of the Virginia Dental Association and partner at Brown, Reynolds, Snow & LeNoir Dentistry. “We send a letter to our patients to let them know what to expect.”
Patients first saw those changes after May 1. Dental offices were mostly closed for several weeks in Virginia beginning in mid-March in response to the pandemic, and protective gear and other safety guidelines were imposed as the offices reopened.
“As an association we looked around in the beginning of March and saw the writing on the wall,” Reynolds says. “In mid-March, we recommended that offices close to anything but emergency medical treatment.”
The VDA realized early on that availability of PPE would be an issue for front-line workers, and its members donated protective gear to hospitals and nursing homes. “We wanted to save it for our comrades on the front line in hospitals,” Reynolds says. “It was also important that we keep dental emergency patients out of the hospital so there would be adequate space for COVID patients.”
The Virginia Commonwealth University School of Dentistry followed the directive to cease elective dental care, but it continued to take care of urgent dental issues. “The Virginia Dental Association and our school were actually ahead of the American Dental Association and the [state] in saying this is dangerous, because dentists work with the mouth and head region,” says Dr. David Sarrett, the school’s dean.
The directive also affected the school’s ability to have its students come in for hands-on patient care training. “We recorded online instruction, but you can’t teach dentists without hands-on work,” Sarrett says. “We are now bringing students back to catch up on simulation classes. Then they will come in during the summer for patient care.”
The New Norm
Dr. Graham Forbes of Capital Dental Design closed his general dentistry practice in March after VDA’s recommendation. “Our office only saw two patients on an emergency basis in a seven-week period,” Forbes says. “I didn’t want to put our team or our patients at more risk than we needed to.”
Reynolds says that her practice conducted a lot of virtual visits with patients through teledentistry. “People across the state were able to do Zoom or FaceTime conferences,” Reynolds says. “We wanted to keep people at home and then determine if they needed to come in.”
The restrictions weren’t lifted until the VDA felt the timing was right. The association worked with the governor’s office to watch how COVID-19 was progressing in hospital systems.
The goal is to ensure the safety of patients, the dental team and the dentists. Reynolds and her office began screening patients on the phone to see if they had COVID-19 symptoms or had been in contact with anyone who did have the virus.
Like many other dental offices, Reynolds’ practice has patients wait in their cars until someone goes out to get them, requires patients to wear a mask in the office and checks patient temperatures. Appointments are staggered so patients can come in one at a time, and plexiglass has been installed to protect the front office staff. The dental team wears full protective gear.
“We use N95 masks with Level Three masks over them and a face shield over that,” Reynolds says. “We have disposable gowns, and we use head wraps. Dentists have always been leaders in infection control protocols.”
Forbes reopened his practice on May 4. “We took a few days to talk about what we wanted to do and have our systems in place to allow the dental team and our patients to be safe,” he says.
His office has also changed the patient flow, asking patients to enter in the back and leave through the front door. “We take our temperatures every morning, and we take the temperatures of patients, too,” he says.
Pre-appointment screening is critical to the safety of dental visits. “Our patients trust us to keep them safe, and we trust them to be honest with us,” Forbes says.
A large percentage of Forbes’ patients are African American, a population that has disproportionately felt the effects of this pandemic.
One of his patients has died from COVID-19. “I saw him in December, and he was a healthy guy,” Forbes says. “I heard he died, and I was shocked and deeply saddened. It makes it more real and present when you know someone who goes to your practice that has died. It raises your awareness of the presence and danger of the virus.”
He has several other patients with immediate family members who have died from COVID-19. “We owe it to our team and our patients to address safety in our office.”
Dr. Thomas Glazier of Richardson, Overstreet & Glazier, a periodontics and dental implant surgery practice, says he and his colleagues follow the guidelines and recommendations of the VDA and the ADA. “We addressed education and separated knowledge from media-based and fear-based myths,” he says. “We wanted to make sure our staff was very comfortable.”
Glazier says that entails full PPE, patient screenings, temperature checks, requiring masks and providing hand sanitizer in the waiting room.
The practice has also installed medical-grade HEPA filter systems in every treatment room as well as the waiting rooms to manage airflow, and aerosol procedures have been eliminated except for emergency care.
“Filters are not the guideline or recommendation, but we are taking the extra step to make patients feel better about air quality,” Glazier says.
The HEPA systems, which some other dentists have also purchased, are an expensive addition to a dental office, at about $900 each. “Some of the newer ones with UV air purification systems cost more,” Glazier says.
Dr. Thomas Glazier (center) with staff sanitizing a work area (Photo by Ash Daniel)
Effects on Dentistry’s Future
Dentists are seeing an economic impact on their practices, especially when it comes to buying equipment. “The prices on masks have gone up from about 99 cents to $10,” Reynolds says.
It’s inevitable that there will be an increase in the cost of dental care and all health care in the long run, VCU’s Sarrett says. “Right now, it’s hard to be as productive as we were before. We still have the same cost of overhead. I think you will see fees start to creep up to cover those costs.”
Reynolds and her team are finding ways to reuse PPE in order to reduce costs. “There are companies that will sterilize masks,” she says, adding that they have had to get used to wearing the PPE. “The N95 mask alone is challenging. It blocks 95% of everything out. It’s difficult to breathe. Then you have an extra outer mask and a face shield. Once you are fully outfitted in PPE, the only thing patients see are your eyes.”
She has a patient who is deaf and reads lips, something that can’t be done when Reynolds is wearing her mask. “I will be researching where I can get masks made for deaf patients,” she says.
Obtaining PPE remains challenging. “It’s hard to get hold of N95 masks,” Sarrett says. “We have gotten a supply of N95 masks, and we are reprocessing N95 masks. Recycling them has greatly extended the life of the masks.”
He finds that face shields don’t work well with dental magnification glasses and headlamps. “We have gone through several different designs. We hope to find some that work with the glasses and headlamps so they don’t distort.”
Sarrett was a teaching and practicing dentist when the HIV/AIDS crisis hit. “We were worrying about infection then,” he says. “We learned certain universal precautions to help stop transmission.”
He believes it would be harder to start a practice now than months ago. “Having said that, I actually do think for new graduates things are really bad now, but I do believe in two to three years, it will be very good for our students,” he says. “There were a lot of dentists poised to retire 10 years ago. I’m hearing a lot of practices say now, ‘I am not coming back.’ There will be a market for new dentists because a lot of practices will be closing down.”