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Dental offices reopen but struggle to meet CDC guidance

When 6-year-old Rosie Weishar’s two permanent teeth erupted, they crowded her baby teeth. But her mom had to wait weeks to take her to the dentist, because offices were closed to all but emergency dental work.
When 6-year-old Rosie Weishar’s two permanent teeth erupted, they crowded her baby teeth. But her mom had to wait weeks to take her to the dentist, because offices were closed to all but emergency dental work.

To meet new standards, dentists may have to scale back appointments, putting patients at risk of not getting needed care

While her daughter’s condition didn’t rise to the level of an emergency, Amanda Weishar was certain the 6-year-old needed immediate medical attention. Two permanent teeth had erupted in Rosie’s mouth, crowding her baby teeth, but no dentist was available to see her.

The issue could have been easily addressed during the child’s routine dental exam. But the visit had been put on hold since thousands of Georgia dentists were ordered to shutter their businesses except for emergencies to help reduce the spread of COVID-19.

“It was really frustrating,” the Alpharetta mother said. “I was concerned.”

» COMPLETE COVERAGE: Coronavirus in Georgia

Now, as dental offices across Georgia reopen and families like the Weishars try to make up for skipped cleanings and routine procedures, they will likely be greeted by a dental staff in an office that looks far different from the days before COVID-19. It might become commonplace, for example, for dentists to be dressed in what looks like space suits, and their dental hygienists to use only hand instruments to remove plaque. Barriers that separate treatment areas could be replaced by walls that help prevent the cross-contamination of patients.

However, dental offices across the U.S., and in states like Georgia, won’t be prepared anytime soon to meet even the minimum requirements and stringent infection control procedures set by the U.S. Centers for Disease Control.

"This is beyond us,'' said Dr. Likith V. Reddy, clinical professor and director of residency training, oral and maxillofacial surgery, at the Texas A&M College of Dentistry in Dallas. "I don't know if we can meet the standard. But I'm sure we won't be fully prepared 100 percent no matter what."

With sanitizers in short supply, Dr. Robert Lee, a southwest Georgia dentist who worked in Atlanta for years, applied for an industrial alcohol license so he could produce hand sanitizers to sell to dental offices throughout the U.S.
With sanitizers in short supply, Dr. Robert Lee, a southwest Georgia dentist who worked in Atlanta for years, applied for an industrial alcohol license so he could produce hand sanitizers to sell to dental offices throughout the U.S.

While dentists have been among the few health care providers who for decades have worn masks and gloves when treating patients, they also work in environments that are at the highest risk of exposure to infectious diseases, like the coronavirus. That’s because practically every procedure conducted in a dentist’s office results in some form of aerosol, produced when devices, such as drills, ultrasonic scalers and air-water syringes, eject spatter or droplets from the mouth into the air and onto clothing and other surfaces.

Less than three weeks ago, the Georgia Dental Association, which represents thousands of the state's dentists, sent a letter to the governor's office expressing concerns that most of its members would not be able to meet the CDC's minimum requirements.

Fears, echoed by industry leaders in other states, are that dentists could be subject to disciplinary action, and some could lose their licenses, if they are found to be in violation of the new requirements.

"It's an unprecedented time,'' said Dr. Alan R. Furness, assistant dean for patient services at the Dental College of Georgia at Augusta University. "We're all trying to be informed and read all the information that comes out and make good, responsible decisions."

One minimum standard of care requires that dental offices provide sufficient and appropriate personal protective equipment, specifically N-95 masks, gowns and disposable gloves, for dental health care personnel to protect them from blood or other body fluids. But, many offices won't be able to locate equipment that is in such short supply and mostly prioritized for hospitals that treat COVID-19 patients.

It will also put a financial strain on Georgia’s more than 4,200 dental practices, which employ 27,800 people, including 5,859 licensed dentists, as well as dental hygienists, laboratory technicians and front desk personnel.

The CDC has set basic expectations for safe practices of dentistry to prevent the spread of the coronavirus. The Georgia Board of Dentistry has said that failure to conform to CDC guidelines for preventing spread of communicable diseases could subject dentists and dental hygienists to discipline.
The CDC has set basic expectations for safe practices of dentistry to prevent the spread of the coronavirus. The Georgia Board of Dentistry has said that failure to conform to CDC guidelines for preventing spread of communicable diseases could subject dentists and dental hygienists to discipline.

“The cost is going to be astronomical,’’ said Dr. Robert Lee, a former Atlanta dentist who now provides care for patients in his tiny hometown of Omaha in south Georgia and neighboring counties stretching to Alabama. “They’re suggesting we wear (new) gowns for every patient and that every employee wear a gown.”

The result is that many dentists will likely have to see one-fourth of the patients they saw prior to the new guidelines, said Lee. To help dental offices control costs, he recently applied for an industrial alcohol license so he could produce up to 5,000 gallons of hand sanitizer a day, which is in short supply all over the U.S.

Meanwhile, as dentists scale back visits, concern is growing that patients won’t be able to access a necessary procedure and could be at risk of serious complications. For example, patients who skip on cleanings and are susceptible to gum disease could face heart disease, diabetes, stroke or pregnancy complications.

Reddy, who also serves as director of the oral and maxillofacial surgery residency program at Baylor University Medical Center in Dallas, has noticed a small uptick of emergency room patients with a tooth abscess that could cause swelling and restrict the airway.

He imagines those cases will increase as patients struggle to find providers.

Tedious and time-consuming

Some say it is reasonable to expect dentists to adapt to the new regulations over time.

A series of workarounds could possibly ease the risk of exposure in many dental offices, industry leaders said. For example, clear shields, rubber dams and domes can be placed around a patient’s mouth in attempts to contain the spatter from an aerosol.

"The cost is going to be astronomical. They're suggesting we wear (new) gowns for every patient and that every employee wear a gown." —Dr. Robert Lee, a former Atlanta dentist

Dental hygienists also can go back to the old-fashioned use of hand instruments to clean the teeth. The instruments can be sanitized after each use, said Dr. Amerian D. Sones, director of continuing education at the Texas A&M College of Dentistry in Dallas.

Sones, like other practitioners, acknowledged that it might be difficult for some dental hygienists to give up their ultrasonic scalers for more time-consuming and tedious hand scaling instruments.

“Some will be concerned and will want to use those ultrasonic scalers,’’ she said, “but maybe for the next couple of years, they will have to use them minimally.”

In Georgia, some dentists said they have dealt with infectious agents for years and are positioned to decide appropriate actions to safeguard their patients and staff. They say they have taken appropriate precautions to prepare to reopen.

Dr. Russ Anderson, a Kennesaw dentist who reopened April 27, said his office disinfects all surfaces in his treatment room, has autoclaves that sterilize equipment and a medical waste system that kills bacteria.

Despite the precautions, he noted that Georgia dentists were told to close before restaurants, bars and nail salons. “We have restaurants open,’’ he wrote in response to questions from the Atlanta Journal-Constitution. “They do not sterilize the forks and knives. They do not disinfect all surfaces. Nail salons, the same thing.”

To some extent, Amanda Weishar, Rosie’s mother, would agree. Why, she asked, is a liquor store considered an essential business, but a dentist is not?

Luckily, Rosie was able to be evaluated by a local dentist, who spent less than five minutes assuring mom that everything was OK.

“Don’t worry,’’ he told her, pointing to Rosie’s baby teeth. “She’s fine. Just have her wiggle them.”

Dental offices urged to make changes

To reduce the risk that patients and staff will be exposed to COVID-19, the American Dental Association has provided various guidelines to dental offices. The guidelines echo the recommendations of the U.S. Centers for Disease Control.

These are among the highlights:

Dental offices must make very effort to interview patients by telephone, text or video conference prior to their visit.

If an emergency or urgent dental patient does not have a fever and is otherwise without even mild symptoms of COVID-19 infection, they can be seen in dental settings with appropriate protocols and personal protective equipment in place.

Practitioners must wear a surgical mask and eye protection with solid side shields or face shield to protect membranes of the eyes, nose and mouth. Surgical masks are one-use only, and one mask should be used per patient.

Practitioners should reduce aerosol production as much as possible as the transmission of COVID-19 seems to occur via droplets or aerosols.

Aerosol-generating procedures should be scheduled as the last appointment of the day. For an aerosol-generating procedure performed without N-95 masks, regardless of disinfection procedures being effectively executed, subsequent patients and staff are at moderate risk for COVID-19 infection and transmission. Given that asymptomatic patients may carry the virus, CDC suggests a 14-day quarantine.