It was early April, when the Covid-19 pandemic was cresting in the Garden State. The last place anyone wanted to be was a hospital emergency room. But one New Jersey woman with a painful wisdom tooth felt she had little choice. The antibiotics she had received two weeks earlier at the same ER hadn’t done much to quell the raging infection. She returned, braving coronavirus exposure for the second time, in her desperation to find relief.
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Instead of receiving treatment, she was told that the hospital, like virtually all the state’s hospitals at the time, was overwhelmed with Covid-19 patients. An ER staffer suggested she try a hospital in Pennsylvania, where the Covid-19 load was lighter. But before she traveled out of state, another hospital referred her to Dr. Philip S. Engel, one of the five oral surgeons of the Oral Surgery Group in New Brunswick and chief of the dental department at Robert Wood Johnson Hospital. Engel was able to extract the tooth and relieve her pain.
During the height of the pandemic, Engel and the four other dentists in his practice saw hundreds of emergencies, from toothaches to dental abscesses in need of draining to traumatic injuries, such as broken jaws. Without access to a dentist’s office, such patients might have sought care in hospital emergency rooms, either to face possible Covid-19 infection or to be turned away (or both).
Dentists who don’t typically deal with emergencies were less likely to see patients in their offices during the pandemic. Dr. Russell M. Sandman, an orthodontist with practices in Hoboken and Closter, treated almost all of his patients remotely, coaching anxious parents via Zoom and FaceTime on how to clip or reshape their children’s out-of-whack wires.
On the other hand, Dr. Anna K. Park, a Mullica Hill endodontist, regularly saw as many as 12 patients a week in her office during the lockdown. She explains that endodontics, which deals with infections of the dental pulp or root, has more emergencies than other dental specialties. The patients she treated, like Engel’s, were those with acute problems who might otherwise have found themselves at hospital ERs.
Whether or not they saw patients during the height of the pandemic, the state’s dentists returned after the lockdown to a field that looked nothing like the one they had previously known. A respiratory infection like the coronavirus, which spreads through droplets and aerosols emitted through the nose and mouth, is particularly dangerous to dentists and their patients. Neither patients nor practitioners were anxious to enter a space that could expose them to a virus that had hit New Jersey with particular vehemence.
Dr. Purnima Hernandez, a pediatric dentist in Fair Lawn, spent much of lockdown attending webinars, including one sponsored by the American Dental Association (ADA) detailing procedures for a safe reopening. One of the key takeaways was the importance of social distancing, including so-called traffic control. Dentists were advised to create routes into and out of their offices that would allow patients to safely distance from one another. Hernandez and her staff spent two weeks setting up her office according to the guidelines, only to discover upon reopening that some plans needed tweaking. “We quickly realized perfect protocols on paper aren’t always functional in action,” says Hernandez. Customizing guidelines to work for their office space solved the problem.
Like most dentists during the time of Covid-19, Hernandez and her staff start safety protocols by phone before an actual appointment, taking a health history—including possible exposure to the coronavirus, current state of health and recent travel to Covid-19 hotspots. As an element of traffic control, she’s rearranged most of the chairs and other furniture from her waiting room; now, only two families can occupy it at once, at a 10-foot distance. Similarly, Park removed everything from her waiting room that couldn’t be sanitized, such as magazines and informational pamphlets.
Like other health practitioners, most dentists have instituted virtual waiting rooms. Patients are advised to text or call the office when they arrive for an appointment. They wait in their cars until the office is ready to admit them. Once in the office, patients are subjected to a regimen that generally includes a temperature check (with a no-touch infrared thermometer), masking (if they enter unmasked) and hand sanitizing.
Dentists and their staff are instituting even stricter protocols for themselves. The personal protective equipment (PPE) donned by Engel and his team has become commonplace throughout the profession. This includes full gowns, N95 masks topped with surgical masks and plastic face shields, hair bonnets, and latex or nitrile gloves. All PPE is fully replaced between patients.
Sandman likens the new protocol to the changes that were put into effect during the HIV epidemic of the 1980s. “Until then, most of us were practicing ‘wet-handed’ dentistry,” he says. “HIV, herpes and hepatitis created an awareness of the need for gloves and masks.” Previously, he notes, dentists routinely contracted herpetic whitlow—a type of herpes infection—on their hands as a consequence of working ungloved.
Sanitizing procedures have also undergone a sea change. These days, it’s not unusual to find offices equipped with HEPA-grade air purifiers in every treatment room and waiting area. Park’s practice recently installed a HEPA-grade HVAC system throughout the entire building. Hernandez added high-volume evacuators, designed to remove aerosolized contaminants (though, she hastens to add, the system is neither proven to remove viruses nor recommended by the Centers for Disease Control).
Dentists are increasingly cautious when it comes to procedures—such as drilling—that create aerosols (fine sprays emitted from the mouth). Park wears safety glasses and wipes them down with antiseptic after each patient.
In many dental offices, surfaces—from spit sinks to dental chairs to high-use objects like pens—are sanitized multiple times throughout the day. Practitioners like Dr. Naren Rajan, a general dentist in Mendham, are increasingly turning to powerful disinfectants, notably hypochlorous acid, a highly effective oxidant that kills bacteria, fungi and viruses much more quickly than traditional disinfectants such as chlorine bleach, but is essentially nontoxic.
While all of these improvements are making dentistry safer during the pandemic, they’re not without their costs, literally and metaphorically. PPE adds significantly to the cost of dentistry, not just because the average dental office goes through so much of the equipment but also because PPE continues to be scarce—and price gouging is a reality. “A gown that should cost 50 cents is now costing $5, and the price of masks has doubled,” says Rajan. In July, the ADA stated that the choice to charge patients for the cost of PPE should be left to individual dentists and recommended that insurers either adjust the maximum allowable fees for all procedures to cover the increased costs of PPE or allow an additional standard fee per date of service per patient. “We got a letter from Delta Dental of New Jersey,” Park says, “that they’d start to pay for PPE starting [in July], but I haven’t seen that happening yet.”
Other costs may be more difficult to pass along to patients and their insurers. “Everything is taking longer,” says Park. “It takes me time to put on the PPE and do the disinfecting between patients. I just can’t go from one room to the next anymore.” For Park and many other dentists, that means seeing fewer patients during the day or working longer hours to make up for lost income.
And then there are the costs that have nothing to do with lost income. Quite simply, all that PPE is hot. And, says Rajan, “when you’re wearing an N95 mask under a face shield, you’re breathing in your own CO2 for most of the day. A lot of us are going to bed at seven or eight o’clock because we’re simply exhausted when we get home.”
Facial protection also makes communicating with patients more difficult. Hernandez is used to fielding questions from parents throughout an office visit; she can’t do that anymore, so she talks with them before and after the procedure. In fact, she says, this is one aspect of the new normal that she’s embraced: “It allows me to focus more on my patient, and I’m actually loving that.”
Patients don’t seem to be balking at the new protocols, most likely because they’re more concerned with safety than comfort, or even cost, at a time when no one knows if or when a second wave of Covid-19 might wash over us. “All of our patients are in great compliance with the new protocols,” says Park.
Just as the HIV epidemic ushered in a new era of masks and gloves, the Covid-19 pandemic is likely to change dentistry forever. While the most stringent protocols, like Plexiglas barriers in waiting rooms, may be abandoned after Covid-19 is no longer a threat, many dentists believe that some changes are here to stay. “Air purification and the use of hypochlorous acid,” says Sandman, “will not change. Wearing level 3 or higher masks with clinical patients will definitely not change.”
He imagines that people wonder how he and other dentists manage to work underneath all the body armor. “Well,” he says, “it’s not easy, but I’d rather not take anything home to my family or anyone else’s.”
NOTE: This story has been updated to correct the American Dental Association’s position on the cost of Personal Protective Equipment.Click here to leave a comment