Dentists Mold Practices for COVID Era

Dr. Whitney Goode, left, Greater Seacoast Community Health dental director, with staff from the Goodwin Dental Center. Courtesy photo.

Following a 10-week shutdown, dental practices are clawing their way back, redesigning patient flow, adopting new safety protocols and trying to hang onto staff in what may be one of the most at-risk occupations during the pandemic.

While dental offices have always followed strict hygiene guidelines, the very nature of the work is a primary risk factor in the pandemic. “We are creating aerosols with most of the activities we are doing,” says Dr. Jonas Westbrook of Applewood Family Dentistry in Barrington.

Dr. Joshua Howard of JD Howard Dental in Dover agrees. “We are probably the highest risk of any profession in the universe.”

Howard is quick to point out, though, that as an industry, dentists’ efforts are paying off. “When you look at the statistics, the number of [COVID-19] clusters originating from dental practices is zero.” He says expanded use of personal protective equipment (PPE), hospital grade HEPA filters and complex patient flow management are all factors in keeping patients safe.

Procuring PPE
Dr. Whitney Goode of the Dental Center at Goodwin Community Health in Somers-worth says they have purchased new face shields, isolation units that reduce aerosols and ordered HEPA filtration units. “There is a lot of waxing and waning within our supply chains since the pandemic started, so we have had to be patient while many of our products have been backordered,” she says. “It certainly takes a lot more time and effort now to ensure we have all of the supplies that we need.”

PPE, the first line of defense, was a hot commodity at the start of the pandemic, with dentists competing with every sector of health care and essential service industries for the limited supply. Dentists give credit to the state for valuing their role in the health care landscape and including them in PPE distribution efforts.

In addition to the NH Dental Society and NH Health and Human Services offering free PPE, Northeast Delta Dental gave 100 free KN95 respirator masks each to dental offices. Staff who normally provide education and outreach delivered the products, says Dr. David Staples of Garrison Family Dental in Dover, who is also chair of the Delta Dental Plan of NH.

LeaAnne Haney of Northeast Delta Dental, center, delivers donated PPE to the Concord dental office of Drs. Ray Orzechowski, right, and Shannon Arndt. Courtesy photo.

Tom Raffio, president and CEO of Northeast Delta Dental in Concord, says they worked in tandem with the dental community. “Through our own reserves, we purchased 110,000 KN95 masks and distributed them to dentists throughout New Hampshire, Maine and Vermont to help them get back up and running. Then we acquired 8,000 gowns and distributed those,” Raffio says. “As our mission is getting people to the dentist, we felt we had to make sure they had what they needed.”

Delta Dental also added $10 per patient to claim payments to help cover the cost of PPE. “Even though we gave them some PPE and the state did as well, we felt it rounds out at about an extra $10 cost per patient.”

Tapping Federal and Local Funds
Like many businesses forced to close, dental practices were able to apply for the federal Payroll Protection Program, which offered low-interest loans (that may be largely forgiven) to meet payroll while businesses were closed.

Westbrook says his practice got approved for PPP in the second or third round, and Howard says the PPP kept him going, “We didn’t really know when we could open as weeks turned into months. My practice, being a larger office, has had some tremendous staffing challenges, and PPP provided the ability to maintain the team,” he says.

Westbrook says the federal loan also allowed them to get through a cash crunch when they first opened since most patients pay through insurance and there was a delay before money started flowing in. Delta Dental also recognized how the delay could affect practices. In addition to processing claims quickly, Raffio says Delta Dental issued relief checks in early March (based on a percentage of the practice’s claim payments in 2019) to help carry them over until they could get back up and running. He says the grants came to about $7 million and on top of that, another $18 million was used to provide premium relief.

“We did a premium holiday for July,” says Raffio. “None of the businesses or individuals had to pay the July bill, this was to help them during this time, especially restaurants. We wanted to make sure no employer dropped dental benefits.”

He says they also fast-tracked their claims operations and moved to twice-weekly check runs so that roughly 99% of claims are processed in five days.

Business Down
Still, with more than two months of closure for all but urgent cases, dentists recognize revenue will be down for the year. While some have reached 80% of normal activity, Howard says, as of August productivity is down about 40%. “It’s not that the patients don’t want to come in, we just don’t have enough team members.”

Goode says most of her team is back but with all the changes they too are hiring. As a federally-qualified community health center, they were able to access different federal relief programs but are feeling the strain. “We have definitely noticed a huge increase in costs of our basic supplies. One example is that a box of level-one masks used to cost about $8 per box is now costing us $24 a box. Similar situations are happening around all of our basic PPE costs,” she says.

Staples expects his revenue will be down about 25% to 30% because of the shutdown. “My guess is the best we will be able to accomplish is about 85% to 90% of our pre-pandemic production going forward if we can avoid another shutdown.”

“We were completely closed for 10 weeks, which is at least a 20% [loss] and now we are operating at a reduced capacity,” says Westbrook. “My guess is we will be off by about 30% to 35% from previous years.”

The New Normal
The American Dental Association recommended that dentists only see emergencies as of March 16 and then state guidance kicked in as well. It was mid-May before they could see non-urgent patients again, but Raffio says it really took until the end of May to ramp back up.

Offices are now scheduling fewer appointments each day, minimizing overlap times to maximize social distancing between patients. When patients arrive, their temperatures are checked with an infrared forehead thermometer, and a standard series of exposure risk questions are asked, then patients are moved quickly into disinfected treatment areas.

Staples says clinical staff now wear additional protective gowns, N95 or KN95 respirator masks and face shields when treating patients. Front office staff wear surgical or cloth masks and work behind glass and Lexan enclosures. Temperatures of staff are also checked and recorded when they arrive to work.

Howard says to accommodate extra screening measures, additional cleaning and new patient flow, he needed more staff but hasn’t been able to hire enough. He adds the pool of skilled labor is at an all-time low as older workers leave for health reasons, and younger workers cannot get licensed as quickly as they are needed.

“In the dental field, we have fewer people than we have ever had,” says Howard. “Other practices are trying to cannibalize our talent pool, salaries are going way, way up, the stress on the dentistry business model is very high. We have improved our compensation and benefits because we know there are others out there trying to steal our team members.”

Both Howard and Westbrook say there are also some staff who have not been able to return to work due to health or family concerns, driving the need for even greater efficiency. Westbrook says his practice is getting more efficient, but the new protocols are driving up more than just labor costs. “There has been a slew of different things introduced into the dental world, it felt like every day there was something new, new shields, new filtration systems, masks, and sneeze guards.” For his practice, Howard invested in a second washer and dryer to clean reusable gowns and hired a team member dedicated to doing laundry all day.

Looking at the long term, there is concern cases could go up. “That is my biggest fear,” Westbrook says. “What will happen next? We are already seeing a spike in other parts of the country. Will there be a mutation in another strain, like 1918?

Even if things stay as they are, we are probably looking at 12 to 18 months of impact.”

Everyone interviewed expects many of the new protocols and technology will remain after a vaccine is developed, and perhaps the new dress code will stay as well. “When this is done, you will see some permanent changes,” says Howard. “I used to wear a shirt and tie, now I wear scrubs.”

Raffio says, as of mid-August, the number of claims was comparable to pre-COVID levels. “Dentists have done a terrific job of managing the new processes. I think our industry is back, and there is a high-degree of patient confidence,” he says. “I just wasn’t sure everyone would be flocking back, but they are. Dentists have been real health care heroes.”