Utah was the first state to allow elective treatment again as Governor Gary Herbert announced that dental practices could resume non-urgent care on April 22 as long as they followed new guidelines. In the ensuing weeks, dentists scrambled to bring their practices, their employees, and themselves up to speed on the new requirements, with many challenges remaining.
Dr. Gary Findley
Gary Findley, DDS, has been practicing general dentistry in Salt Lake City for about 20 years. He and his team, which includes two hygienists, have an older patient population. So when the ADA and the Utah Dental Association recommended restricting care to emergency treatment, he made changes right away.
“My patients have been with me a while. They’re older. We stuck right to it because I see a lot of vulnerable people. We shut down and were in emergency mode,” Findley said.
For the next four or five weeks, Findley said, he primarily treated root canals in addition to a couple of broken teeth. When patients called, his team asked them if they were in pain as they tried to assess the level of urgency. When patients weren’t suffering, their care was postponed. During that time, he said, he was in the office for two half days a week.
“Someone calls and says ‘I have a tooth that’s hurting me.’ We would ask, ‘How long has it been hurting?’ If it’s something that came on last night and you can’t sleep, that’s pretty urgent. If on the other hand they’re saying ‘Yeah, this thing has been bugging me off and on for two months,’ then perhaps we can give them an antibiotic,” Findley said.
Most of the chairs were removed from the waiting room, and acrylic barriers were installed. Patients would wait in the parking lot, and they would be called in by text. Temperatures were taken, and questionnaires were administered. Also, his administrative team worked from home, tending to billing and scheduling matters online and by phone.
Personal protective equipment (PPE) was another significant adjustment, often making care slower and more awkward.
“It’s a pain in the neck. When I first got this stuff on, I had my face shield, my N95 mask, my surgical gown on there. I would have walked into the wall. I’m fogging up. My face shield is reflecting light from the light that’s attached to my loupes. It’s blinding me,” he said. “I had to modify my face shield just to be able to do my job.”
The shortages left Findley and his team working with whatever PPE they could find. But the equipment has improved since those early days, he said, particularly the face shields. He also compared the changes to when he was in dental school in the late 1980s, when protocols adapted to accommodate the HIV and AIDS crisis.
“At that time, a lot of the old timers worked most of their career without gloves. You heard people griping that they can’t do anything. They lost their tactile sense. So I wonder now if a lot of this stuff will carry over. It’s going to change things from here on out. To what extent, that remains to be seen,” Findley said.
Access to PPE was a big part in Findley’s reopening plans. Opening up sooner would have required some compromises, he said, and waiting an extra week to do so enabled him to get him what he needed. And while availability is improving, he and his colleagues still compare notes about the best sources for gear.
These PPE and other infection control protocols are remaining in place as Findley’s scope of practice has begun incorporating more care, though it’s still a very reduced schedule. He only keeps one hygienist on duty at a time because of the risks of aerosols. He also is more selective in what he’s performing. Veneer kits, for instance, are still being postponed.
“On the other hand, someone who has been wearing a flipper waiting for their implants to be restored, they’re pretty anxious for some front teeth,” he said. “We’re going to do that. We’re going to take impressions on that. So we’re doing more than emergency or essential work. We’re doing maybe what I would consider somewhat urgent work.”
Some patients are reluctant to return to the office, and Findley has reduced his hygiene schedule. He is now easing into his backlog of cases, including routine restorative care, though he suspects things may slow down again once he gets past the initial waiting list. The schedule may be light, but that gives him more time for operatory turnover anyway—or conversation.
“Some people are really bottled up because they’ve been self-isolating. We kind of slowed down. Well, hygienists are kind of like bartenders for my patients,” Findley said. “I don’t think they’ve been having a lot of personal interaction for some time. I swear, just the amount of chit-chat. People with a lot to say, and they just want to take the time to say it. And that’s actually put us behind because people seem to want to talk a little bit more.”
Dr. Mark Pettit
Mark Pettit, DDS, also has a small general practice in Salt Lake City with a hygienist and now two assistants, recently hiring the second to help with changes caused by the new protocols. Seeing the shutdown coming, he and his team contacted their patients via email to let them know they would be available for urgent and emergency care. They wound up seeing a handful of patients each day, though he said he didn’t see any full days of work.
“We had one lady come in. I thought her tooth was going to blow up from the phone call. She just had a broken side of her tooth, and we just put her back together. The patient’s perspective is different from mine sometimes. But that’s okay. It’s always to a patient, when something breaks, it’s an emergency and they’re panicky,” he said.
The lighter schedule enabled Pettit to space patients out better so he wouldn’t see two at the same time, though he does have a consult room to use for overflow purposes. Like Findley and other practices, Pettit would have patients wait in the parking lot and then call them when the office was ready to see them.
Also like Findley, Pettit graduated from dental school in the wake of the HIV and AIDS epidemic, so his entire experience has been in universal precautions. His front office also now uses plexiglass barriers, and everyone there needs to wear a mask. Temperatures and questionnaires are taken as well, and signage explains the new precautions.
“When a patient has called to confirm they’re coming in, we go over a couple of things just to prepare them ahead of time. Just to give them a head’s up of what’s going on to let them know we’re here. We’ve made some changes. And we’ll continue to make changes as we can,” Pettit said, though one change hasn’t been so pleasant.
“Peroxide rinses. They’re awful tasting,” he said. “We actually have the patient rinse. We have the staff sit with a timer, 60 seconds, so they rinse and spit out. Patients are fine with it. They all want to do what they can as well.”
According to Pettit, his practice is now running “business as usual,” though at about 75% of full speed. He also said that as a small practice, he hasn’t been as impacted as larger practices have been. He is offering all services, including hygiene. Also, he said he is careful with aerosols and trying to avoid ultrasonics when possible.
“We’ve been open two weeks and we haven’t used the ultrasonic yet, which is hard for the hygienist. We’re trying to make conscious decisions to do things differently,” he said.
Another challenge has been the deluge of recommendations from multiple sources about how to safely practice.
“We’re in information overload right now. I had to get a little more selective,” Pettit said, noting that he used guidelines from the Utah Dental Association, his local district, the ADA, the state’s health department, and his malpractice carrier.
“I feel confident with those people, but we still have to make some decisions on our own,” he said. “Now we just have to make sure we’re protecting everyone. We don’t know how this is going to work out. So the fact that I get to practice dentistry right now, I feel really lucky. I feel privileged.”
Caution remains, however. If infection rates increase, Pettit acknowledged, then practices may have to shut down again. He also said that PPE remains difficult to acquire, with many items still on back order, though he has plenty of masks. He does feel that dentistry has been left behind in PPE distribution, however.
“When we shut down our offices, part of the idea was to funnel more supplies to the hospitals and help take care of people, which is fine. We all wanted to do that. I actually considered taking some of my masks up to the hospital,” he said, adding that once restrictions were loosened, a colleague called the state about the short PPE supplies for dentists.
“They said ‘We forgot about the dentists,’” Pettit said. “So they threw us a bone. They handed out some face masks and N95 masks. I got 10 N95 masks and I think eight face shields, and they said ‘Hey, try to share with people in your building.’ We kind of gave up a little bit to help other people, and we kind of feel like at times we were forgotten.”
Pettit thinks that these changes are going to be permanent as well.
“We’ve got to sit back, and we’ve got to find some balance because we’re going to see some changes, in my opinion, over the next months and several years. And we’re going to have to look back, and some of these things will be really good and practical, and some things might not be that great. But they might be expensive.”
This evolution should be driven by evidence, he said, especially as practices begin investing in big-ticket items like ultraviolet lights and air filters.
“I’d like to see what the science is because we might spend a lot of money on pretty expensive systems, but it’s really not making you or your patients and safer. There are things we kind of need. Where’s the science? Can we validate that these things are really helpful before we start spending a lot of money and not really improving our patients’ safety?” he said.
“We kind of went through this with the whole HIV thing in the ‘80s and ‘90s, and eventually we all settled in and found our groove and found what was working and what was not,” he said. “It will happen again.”
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