Ann Enkoji usually likes to see her dental hygienist, but when her dentist’s office in Santa Monica, California canceled her cleaning visit last spring, she was relieved.
She was cautious about 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 very close to the nasal mouth area,” said Enkoji, 70, a marketing design consultant based in Santa Monica.
When she returned to the dentist’s office in September for cleaning, she was asked to wash her hands and use an antimicrobial mouthwash, measures that federal health guidance said could help stop the spread of germs in aerosols and splashes during the treatment.
Without a doubt, dentistry is among the most intimate health professions. Patients must keep their mouths open while dentists and hygienists work on the inside with mirrors, scrapers, probes and, until recently, those drills that cause fear.
These exercises and other electrical equipment, including ultrasonic scrapers and air polishers, can produce suspended drops or aerosols that can be suspended in the air, potentially carrying the virus that can endanger patients and staff.
Today, dental offices operate in a remarkably different way than they did before the pandemic. Since reopening in May and June, they have followed federal guidelines and recommendations from industry groups aimed at reducing Covid’s spread.
Los Angeles County, where Enkoji lives, has exceeded 1.4 million cases, and New York City has reported more than half a million cases.
And while vaccination offers new promise, there are new concerns about the most contagious variants of the virus, as well as a calendar of months for vaccines to be released to the general public.
Many dental offices have remained open in recent months, with dentists and hygienists equipped with face shields, masks, aprons, gloves and hair protectors that resemble shower caps. They reserved aerosol-expelling electrical equipment, and hygienists instead rely on traditional hand tools to remove plaque and tartar accumulated in patients.
According to the new practices, patients are usually called a few days before visits and are asked if they have any symptoms of Covid. They can be instructed to wait in their cars until they can be seen. Their temperatures can be measured before entering a dental office, and they must wear masks, except during treatment, all measures recommended by the US 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 in Staten Island, the waiting area is devoid of magazines and plexiglass protectors have been installed at the reception, said Dr. Craig Ratner, owner of the Tottenville neighborhood office.
And visits can last longer, because scaling manually is more laborious than applying ultrasonic scalers and because some patients have accumulated tartar, stains and plaque on their teeth due to pandemic-related gaps in visits, said Dr. Ratner, who is president of New York State Dental Association.
“It is unfortunate, but understandable,” he said.
This revolution in dental protection equipment was compared to the one that accompanied HIV/AIDS pandemic, when many dentists started wearing gloves and masks for the first time, according to an article in the journal JDR Clinical & Translational Research.
“Dentistry has changed – it’s amazing how it has changed in the past 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 in early February when Dr. William V. Giannobile, dean and professor at Harvard School of Dental Medicine in Boston, heard from a colleague in Wuhan, China.
The dean of the faculty of dentistry in Wuhan, where the coronavirus was first reported on New Year’s Eve 2019, asked Dr. Giannobile if he would help to have his team’s findings republished in the United States.
The authors of the article, which would appear in The Journal of Dental Research, established basic safety measures that would later be adopted by thousands of American dentists.
“They showed that the provision of dental care is safe and that guidelines can be implemented to screen patients and provide dental care,” said Dr. Giannobile.
These guidelines include not only the now ubiquitous use of staff protective equipment, but also questions before the visit, temperature checks and the use of masks by patients. And the Wuhan researchers said that “in areas where Covid-19 spreads, non-emergency dental practices must be postponed” – advice endorsed at the beginning of last year by the CDC and the American Dental Association.
The closing of dental companies in the spring caused many difficulties for many dental offices. Only 3 percent of offices in the United States remained open in March and April, and layoffs led to the disappearance of more than half of dental office jobs, said Marko Vujicic, chief economist at ADA
“This was an unprecedented event in dentistry,” said Vujicic. But when the doors opened in late spring, the number of patients skyrocketed.
His association has sought permission to provide tests for the virus across the country, as well as to administer Covid vaccines. Dentists have been authorized to administer the vaccine in 20 states, including California, Connecticut, New Jersey and New York, the ADA survey showed.
Dentists top the priority lists for those eligible to receive the vaccine, with Stage 1a status in 40 states. The CDC recommends that dental hygienists and assistants also be included in the list of priority vaccines.
In New York City, the School of Dentistry at New York University suspended personal visits last winter, but resumed urgent cases in late June. Since then, she has treated more than 700 patients a day, said Elyse J. Bloom, associate dean of the college. And her mandatory virus test for students and faculty and staff members helped keep the college’s positive case count significantly lower than New York’s overall, she said.
Fear of job loss has spread across the industry.
“This was a very scary time for many people,” said JoAnn Gurenlian, a professor of dental hygiene at Idaho State University who leads an American Dental Hygienists Association task force.
More than half of dental hygienists, dental therapists and oral health experts reported that they were not working on a June 2020 survey conducted by the International Federation of Dental Hygienists. Half said they were deeply concerned about not having enough personal protective equipment to treat patients.
Patients are also anxious. Some dentists found themselves treating stressed clients who gritted their teeth while sleeping and needed devices to prevent splinters or fractures.
“Honestly, I’ve made a lot of night watchmen,” said Dr. Todd C. Kandl, who spent 13 years building his family clinic with a team of eight in East Stroudsburg, Pennsylvania, nestled in Poconos.
Forced to close the clinic in mid-March, Kandl received a federal loan that allowed him to reopen on June 1, he tried to diagnose patients’ conditions over the phone, he said. Now, most of his patients have returned.
He and his team follow the CDC guidelines, putting on a clean robe for each patient and changing it later. They wash all the dresses in the office.
He installed a series of updates recommended by the CDC, including high-efficiency particulate air, or HEPA, filter units to retain fine particles. And he bought several suction systems that remove drops and aerosols, as well as ultraviolet light to help with hygiene.
Dr. Kandl also decided to stop using nitrous oxide, a gas used to gently sedate and relax anxious dental patients. In the past, he rarely used the gas, but in the midst of 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, business manager for a family-owned dental practice in Hawaii, said living on the island has resulted in transportation problems in obtaining the protective equipment her employees need.
“Our masks and gloves are being rationed by our main dental suppliers,” said Ms. Uehara. The dresses ordered four months ago have finally arrived. And prices are going up. “We used to pay about $ 15 for a box of gloves. Now they are charging $ 40 to $ 50 a box. “
But, like other dentists, she is now a veteran of uncertainty. If the lack of protective equipment means reducing the number of patients, “then that is what we will do,” she said.
The Uehara family has offices in Honolulu, Oahu, and Hilo, on the Big Island of Hawaii. Pandemic blocks hamper your practices. Family members travel between the two islands in a commercial jet, posing another risk.
The reopening was slow, but the patients came back. “I heard the sound of laughter in the office,” said Ms. Uehara.
An increase in coronavirus cases among children also presented challenges for pediatric dentists.
In early December, the CDC strongly endorsed school programs in which dentists apply thin coatings called sealants to the back teeth of children in third to fifth grades. These sealants are especially useful for children at risk of 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 was turning to more conservative methods of dealing with tooth decay now that some drills and tools can increase the risk of contagion.
Dr. Chi, who attends the Odessa Children’s Clinic in Seattle, said one way to prevent perforation was to put 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. The application of such crowns usually requires numbing the tooth, using a drill to remove caries and reshaping the tooth, and then installing the crown.
A more conservative approach: placing a crown directly on the baby tooth without removing cavities or remodeling. The evidence suggests that it is as effective as the traditional approach, takes less time and is more economical, said Dr. Chi.
“Covid really encouraged dentists to look at all the options you have for treating dental disease,” he said.
Some dentists, however, may choose to leave the profession. The ADA conducted a survey asking dentists how they would react if visits to patients remained the same for several months.
“Our data shows that 40% of dentists aged 65 and over would seriously consider retirement in the coming months if the volume of patients remains as it is today,” said Dr. Vujicic.
Over time, however, some patients have learned to adjust.
Enid Stein of Staten Island has visited Dr. Ratner’s office five times since his reopening for implant surgery and new crowns. She describes herself as germophobic, carries spray alcohol in her wallet, 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.”