Dental Practices Change in the Covid Era

The pandemic has forced dentists and hygienists to change some of the methods for maintaining good oral hygiene, to protect patients as well as themselves.

Ann Enkoji normally enjoys seeing her dental hygienist, but when her dentist’s office in Santa Monica, Calif., canceled her cleaning visit last spring, she felt relieved.

She had been wary of keeping the appointment anyway, worried about someone else’s fingers and instruments exploring her mouth at a time when more than 25,000 Americans were contracting the coronavirus daily.

“It’s just too up close in that mouth-nasal region,” said Ms. Enkoji, 70, a marketing design consultant based in Santa Monica.

When she returned to her dentist’s office in September for a cleaning, she was asked to wash her hands and use an antimicrobial mouth rinse, steps that federal health guidance said might help curb the spread of germs in aerosol and splatter during treatment.

Without a doubt, dentistry is among the more intimate health professions. Patients must keep their mouths wide open as dentists and hygienists poke around inside with mirrors, scalers, probes and, until recently, those cringe-inducing drills.

Such drills and other power equipment, including ultrasonic scalers and air polishers, can produce suspended droplets or aerosol spray that may hang in the air, potentially carrying the virus that could endanger patients and staff.

Today, dental offices operate in a markedly different way than they did pre-pandemic. Since reopening in May and June, they have been following federal guidelines and industry group recommendations aimed at curtailing the spread of Covid.

Los Angeles County, where Ms. Enkoji lives, passed 1.4 million in cases, and New York City has reported more than half a million cases.

And while vaccination offers fresh promise, there are new worries about more contagious variants of the virus as well as a months-long timetable for rolling out the vaccines to the general public.

Many dental offices have stayed open in recent months, with dentists and hygienists geared up in face shields, masks, gowns, gloves and hair covers resembling shower caps. They have set aside aerosol-spewing power equipment, and hygienists instead rely on traditional hand tools to remove patients’ built-up plaque and tartar.

Under the new practices, patients typically get called a few days before visits and are asked if they have any Covid symptoms. They may be told to wait in their cars until they can be seen. Their temperatures may be taken before entering a dental office, and they have to wear masks, except during treatment, all measures recommended by the U.S. Centers for Disease Control and Prevention.

Dental offices also look different now. Many dentists are allowing only one patient in the office at a time. At Exceptional Dentistry on Staten Island, the waiting area is bereft of magazines, and plexiglass shields have been installed at the front desk, said Dr. Craig Ratner, owner of the office in the Tottenville neighborhood.

Jonno Rattman for The New York Times
Jonno Rattman for The New York Times

And visits may last longer, because scaling by hand is more laborious than applying ultrasonic scalers, and because some patients have built-up tartar, stains and plaque on their teeth stemming from pandemic-related gaps in visits, said Dr. Ratner, who is president of the New York State Dental Association.

“It’s unfortunate, but understandable,” he said.

This revolution in dental protective gear has been compared to the one that accompanied the HIV/AIDS pandemic, when many dental workers began wearing gloves and masks for the first time, according to an article in the journal JDR Clinical & Translational Research.

“Dentistry has changed — it’s incredible how it has changed over the last few months,” said Dr. Donald L. Chi, a pediatric dentist and professor of oral health sciences and health services at the University of Washington.

Covid-19 had barely touched the United States early last February when Dr. William V. Giannobile, dean and professor at the Harvard School of Dental Medicine in Boston, heard from a counterpart in Wuhan, China.

The dean of the dental school in Wuhan, where the coronavirus was first been reported on New Year’s Eve in 2019, asked Dr. Giannobile if he would help get his team’s findings republished in the United States.

The authors of the article, which would appear in The Journal of Dental Research, laid out basic safety measures that would later be adopted by thousands of U.S. dentists.

“They showed that the provision of dental care is safe and that guidelines could be put in place to triage patients and provide dental care,” Dr. Giannobile said.

Those guidelines include not only the now-ubiquitous use of staff protective gear, but also pre-visit questions and temperature checks and patients’ use of masks. And the Wuhan researchers stated that “in areas where Covid-19 spreads, nonemergency dental practices should be postponed” — advice endorsed early last year by the C.D.C. and the American Dental Association.

The springtime shuttering of dental businesses caused a lot of hardship for many dental practices. Only 3 percent of those offices in the United States stayed open in March and April, and layoffs and furloughs led to the disappearance of more than half of dental-office jobs, said Marko Vujicic, the chief economist for the A.D.A.

“This was an unprecedented event in dentistry,” Mr. Vujicic said. But when doors swung open later in the spring, the number of patients soared.

His association has been seeking permission to provide tests for the virus nationwide, as well as to administer Covid vaccines. Dentists were allowed to administer the vaccine in 20 states, including California, Connecticut, New Jersey and New York, A.D.A. research showed.

Dr. Donald L. Chi, who practices at the Odessa Children’s Clinic in Seattle, says that one way that he avoids drilling — and unnecessarily spreading the virus — is to place silver diamine fluoride on a child’s baby tooth to prevent a cavity from growing.
Jovelle Tamayo for The New York Times

Dentists rank high on the priority lists for those eligible to get the vaccine, with Phase 1a status in 40 states. The C.D.C. recommends that dental hygienists and assistants also be included on the vaccine priority list.

In New York City, the College of Dentistry at New York University suspended in-person visits last winter, but resumed urgent cases in late June. Since then, it has treated more than 700 patients a day, said Elyse J. Bloom, associate dean of the college. And its mandatory virus testing for students and members of the faculty and the staff has helped keep the college’s count of positive cases significantly lower than that of New York City over all, she said.

Fear of job losses has rippled through the industry.

“This was a very frightening time for many individuals,” said JoAnn Gurenlian, a professor of dental hygiene at Idaho State University who heads a return-to-work task force for the American Dental Hygienists Association.

More than half of dental hygienists, dental therapists and oral health specialists reported that they were not working in a June 2020 survey conducted by the International Federation of Dental Hygienists. Half said they were deeply concerned that they would not have enough personal protective gear to treat patients.

Patients, too, have been anxious. Some dentists have found themselves treating stressed clients who were grinding their teeth in their sleep and needed devices to prevent chips or fractures.

“Honestly, I’ve made a lot of night guards,” said Dr. Todd C. Kandl, who has spent 13 years building up his family practice with a staff of eight in East Stroudsburg, Pa., tucked away in the Poconos.

Forced to close the practice in mid-March, Dr. Kandl received a federal loan that allowed him to reopen on June 1. In between, he tried to diagnose patients’ conditions over the phone, he said. Now, most of his patients have come back.

He and his staff follow C.D.C. guidelines by putting on a clean gown for each patient and changing it afterward. They launder all gowns at the office.

He has installed a number of the upgrades recommended by the C.D.C., including high-efficiency particulate air, or HEPA, filter units to trap fine particles. And he purchased several suction systems that remove droplets and aerosols, as well as ultraviolet light to help sanitize.

Dr. Kandl also chose to discontinue use of nitrous oxide, a gas used to mildly sedate and relax anxious dental patients. In the past, he rarely used the gas, but amid the Covid-19 outbreak, he grew concerned about his system, an older type that wasn’t worth the risk of exposing patients.

Lynn Uehara, 55, the business manager for a Hawaii family dental practice, said that island living had resulted in shipping problems to obtain the protective gear that her employees need.

“Our masks and gloves are being rationed by our main dental suppliers,” Mrs. Uehara said. Gowns ordered four months ago finally arrived. And prices are soaring. “We used to pay about $15 for a box of gloves. Now they are charging us $40 to $50 a box.”

But like other dental workers, she is now a veteran of uncertainty. If the lack of protective gear means reducing the number of patients, “then that’s what we will do,” she said.

Jonno Rattman for The New York Times
Jonno Rattman for The New York Times

The Uehara family has offices in Honolulu on Oahu and in Hilo, on the Big Island of Hawaii. The pandemic lockdowns hurt its practices. Family members commute between the two islands by commercial jet, posing another risk.

The reopening went slowly, but patients have returned. “I’ve heard the sound of laughter back in the office,” Mrs. Uehara said.

A surge in coronavirus cases among children has also posed challenges for pediatric dentists.

In early December, the C.D.C. strongly endorsed school-based programs in which dentists apply thin coatings called sealants on the back teeth of children in third through fifth grades. Such sealants are especially helpful for children at risk of cavities and for children whose families can’t afford private dentists, the agency said.

Dr. Chi, the pediatric dentist and University of Washington professor, said that dentistry was turning to more conservative methods of dealing with tooth decay now that some drills and tools might heighten the risk of contagion.

Dr. Chi, who practices at the Odessa Children’s Clinic in Seattle, said that one way that he avoided drilling was to place silver diamine fluoride on a child’s baby tooth to prevent a cavity from growing.

He can also select stainless steel crowns to block the growth of a cavity. Applying such crowns normally requires numbing the tooth, using a drill to remove decay and reshape the tooth, and then installing the crown.

A more conservative approach: placing a crown directly on the baby tooth without removing decay or reshaping. Evidence suggests that it is as effective as the traditional approach, takes less time and is more cost-effective, Dr. Chi said.

“Covid has really encouraged dentists to look at all the options you have to treat dental disease,” he said.

Some dentists, however, may choose to leave the profession. The A.D.A. conducted a survey asking dentists how they would react if their patient visits remained the same for several months.

“Our data show that 40 percent of dentists 65 and older would seriously consider retiring in the coming months if patient volume remains at what it is today,” Dr. Vujicic said.

Over time, though, some patients have learned to adjust.

Enid Stein of Staten Island has visited Dr. Ratner’s practice five times since it reopened, for implant surgery and new crowns. A self-described germaphobe who carries alcohol spray in her pocketbook, she brought her own pen to pay by check.

“I’m done, thank God,” she said. “Not that I don’t mind seeing him and all the girls in the office, but I’m in good shape.”

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