Ann Enkoji usually enjoys seeing her dentist, but when her dentist’s office in Santa Monica, California, canceled her cleaning visit last year, she felt relieved.
In any case, she was careful to keep the appointment, worried about someone else’s fingers and instruments exploring her mouth at a time when more than 25,000 Americans contracted the coronavirus daily.
“It’s just too close in the mouth – nose area,” said Ms. Enkoji, 70, a marketing design consultant in Santa Monica, said.
When she returned to her dentist’s office in September for cleaning, she was asked to wash her hands and use an antimicrobial mouthwash. This is according to the federal health guidelines the spread of germs in aerosol and splashes during treatment.
Dentistry is without a doubt one of the more intimate health professions. Patients should keep their mouths wide open while dentists and hygienists stick around with mirrors, scalers, probes and until recently with the itchy drills.
Such drills and other power equipment, including ultrasonic exfoliators and air cleaners, can produce hanging droplets or aerosol sprays that can hang in the air, potentially carrying the virus that can endanger patients and staff.
Currently, dental offices operate in a very different way than they did pre-pandemic. Since reopening in May and June, they have been following federal guidelines and industry group recommendations to limit the spread of Covid.
Los Angeles County, where Mrs. Enkoji lives, reported 1.4 million cases, and New York City reported more than half a million cases.
And while vaccination offers fresh promise, there are new concerns about the more contagious variants of the virus, as well as a month-long roster to introduce the vaccines to the general public.
Many dental offices have remained open in recent months, with dentists and hygienists fitted in face masks, masks, gowns, gloves and hair coverings such as shower caps. They have set aside aerosol saliva equipment, and hygienists are relying more on traditional hand tools to remove patients’ accumulated plaque and tartar.
According to new practices, patients are usually called a few days before visits and asked if they have any Covid symptoms. They can be told to wait in their cars until they can be seen. Their temperature can be taken before going to a dental office, and they must 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 allow only one patient into the office at a time. In Exceptional Dentistry on Staten Island, there are no magazines in the waiting area, and plexiglass screens have been installed at the reception desk, said Dr. Craig Ratner, owner of the office in the Tottenville neighborhood, said.
And visits can take longer because manual scaling is more difficult than applying ultrasonic scales, and because some patients have built-up tartar, stains and plaque on their teeth due to pandemic related gaps in visits, Drs. Ratner said. president of the New York State Dental Association.
“It’s unfortunate, but understandable,” he said.
This revolution in dental protective equipment has been compared to the one that accompanied HIV/Aids pandemic, when many dental workers first started wearing gloves and masks, according to an article in the journal JDR Clinical & Translational Research.
“Dentistry has changed – it’s amazing how it’s changed in 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 barely hit the United States in early February when dr. William V. Giannobile, dean and professor at the Harvard School of Dental Medicine in Boston, heard from a peer in Wuhan, China.
The dean of the dental school in Wuhan, where the coronavirus was first reported on New Year’s Eve in 2019, said dr. Giannobile asked if he would help have his team’s findings republished in the United States.
The authors of the article, which would appear in The Journal of Dental Research, set out basic safety precautions that would later be adopted by thousands of American dentists.
“They have shown that the provision of dental care is safe and that guidelines can be put in place to expel patients and provide dental care,” said Dr. Giannobile said.
These guidelines include not only the use of personal protective equipment, but also questions and temperature controls and patients’ use of masks. And the Wuhan researchers said that “in areas where Covid-19 is spreading, dental practices should be postponed” – advice approved by the CDC and the American Dental Association early last year.
The spring closure of dental businesses has caused many problems for many dental practices. Only 3 percent of the offices in the United States remained open in March and April, and layoffs and plans led to the disappearance of more than half of the dental posts, said Marko Vujicic, the chief economist of the ADA.
“It was an unprecedented event in dentistry,” he said. Vujicic said. But when the doors swung open later in the spring, the number of patients skyrocketed.
His association has asked for permission to conduct nationwide tests for the virus, as well as to administer Covid vaccines. Dentists have been allowed to administer the vaccine in 20 states, including California, Connecticut, New Jersey and New York, ADA research has shown.
Dentists are high on the priority lists for those eligible to receive the vaccine, with Phase 1a status in 40 states. The CDC recommends that dental hygiene and assistants also be included on the priority list for vaccines.
In New York City, the College of Dentistry suspended visits to New York University last year, but urgent matters resumed in late June. Since then, it has treated more than 700 patients a day, said Elyse J. Bloom, dean of the college. Its mandatory virus testing for students and faculty and staff members has helped keep the number of positive cases in college significantly lower than that of New York.
The fear of job losses has passed through the industry.
“It was a very scary time for many individuals,” said JoAnn Gurenlian, a professor of dental hygiene at Idaho State University who heads a task force for the American Dental Hygienists Association.
More than half of dentists, dental therapists and oral health specialists reported not doing so 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 equipment to treat patients.
Patients were also anxious. Some dentists have found that they treat stressed clients who have gritted teeth in their sleep and needed devices to prevent chips or fractures.
“Honestly, I built up a lot of night guards,” said Dr. Todd C. Kandl, who has been hiding his family practice for 13 years with a staff of eight in the East Stroudsburg, PA, in the Poconos said.
Forced to close the practice in mid-March, dr. Kandl obtained a federal loan that enabled him to reopen on June 1st. In the meantime, he tried to diagnose patients’ conditions telephonically, he said. Now most of his patients have returned.
He and his staff follow CDC guidelines by putting on a clean gown for each patient and changing it afterwards. They were all gowns at the office.
He has installed a number of upgrades recommended by the CDC, including high-efficiency particulate air, or HEPA filter units to capture particulate matter. And he has purchased several suction systems that remove droplets and aerosols, as well as ultraviolet light to help disinfect.
Dr. Kandl also decided to discontinue the use of nitric oxide, a gas used to gently calm and relax anxious dental patients. In the past, he rarely used the gas, but amid the Covid-19 outbreak, he became concerned about his system, an older type that was not worth the risk of exposing patients.
Lynn Uehara, 55, the business manager of a family-owned dental practice in Hawaii, said island living has led to shipping problems to get the protective equipment her employees need.
“Our masks and gloves are rationed by our major dental providers,” she said. Uehara said. Gowns ordered four months ago have finally arrived. And prices are rising. ‘We used to pay about $ 15 for a box of gloves. Now they charge us $ 40 to $ 50 per box. ”
But like other dental workers, she is now a veteran of uncertainty. If the lack of protective equipment means reducing the number of patients, “that’s what we will do,” she said.
The Uehara family has offices in Honolulu on Oahu and in Hilo, on the Big Island of Hawaii. The closure of the pandemic harms its practices. Family members commute between the two islands on a commercial plane, which poses another risk.
The reopening was slow, but patients returned. “I heard the laughter in the office again,” Ms Uehara said.
A resurgence in cases of coronavirus among children has also posed challenges for pediatric dentists.
In early December, the CDC had a strong endorsement in school-based programs in which dentists apply thin coverings to the back teeth of children in third to fifth grade, called a dressing. Such sealants are especially helpful for children walking cavities and for children whose families cannot afford private dentists, the agency said.
Dr. Chi, the pediatric dentist and professor at the University of Washington, said dentistry is concentrating on more conservative methods of dealing with tooth decay, as some exercises and tools can increase the risk of infection.
Dr. Chi, who practices at the Odessa Children’s Clinic in Seattle, said one way to avoid drilling was to place silver diamine fluoride on a child’s baby tooth to prevent a cavity from growing.
He can also choose stainless steel crowns to stop the growth of a cavity. To apply such crowns, the tooth must be anesthetized, a drill used to remove spoilage and reform the tooth, and then the crown installed.
A more conservative approach: to place a crown directly on the baby tooth without removing spoilage or reforming. Evidence suggests that it is just as effective as the traditional approach, that it takes less time and is more cost-effective, Drs. Chi said.
“Covid really encouraged dentists to look at all the options you have to treat dental diseases,” he said.
However, some dentists may prefer to leave the profession. The ADA conducted a survey in which dentists were asked how they would respond if their patient visits remained the same for several months.
“Our data show that 40 percent of dentists 65 years and older will seriously consider retiring in the coming months if the patient’s volume remains as it is today,” said Dr. Vujicic said.
Over time, however, some patients have learned to adapt.
Enid Stein of Staten Island has since the reopening of Dr. Ratner’s practice visited five times for implant surgeries and new crowns. A self-described kitchen, which carries alcohol abuse in its pocketbook, brings her own pen to pay by check.
“I’m done, thank God,” she said. “Not that I do not mind seeing him and all the girls in the office, but I’m in good shape.”