Is It Safe?

I’ve been in solo practice for almost 34 years now. I own my own practice and am my own boss. I chose this route because I wanted to be the Captain of my own ship and never have to worry about a job. Moreover, I’m a bit lazy and have problems with authority, so I would have made a terrible employee in any field. So imagine my surprise when suddenly during the first week of March, I had to completely shut down my dental practice. Well, not completely, as I was able to go in to see emergencies a couple of times each week, but basically I was laid off by a “boss” that measured a measly 120 nanometers across. I wasn’t alone; nearly every dental practice in the US came to a screeching halt by mid-March, following national, state, and local guidelines.

At the time, we dentists were flying blind. Very little information about the SARS-CoV-2 pandemic was known, and what we were learning changed daily. This was compounded by the fact that the dental profession is among the highest risk groups at being exposed to the coronavirus (See Figure 1). Some dentists believed we should remain open to see patients, making sure to take extra infection control precautions. Others thought that everything should be shut down completely and immediately until enough data was available to make informed choices as to the appropriate responses to this crisis should be. And yet another group lobbied for dental offices being open to treat emergency patients in order to nip problems in the bud and to help alleviate dental related visits to hospital Emergency Departments that might need to be utilized for acute COVID cases. These decisions were made for the most part at the state level. Here in Kansas, we had to shut down completely except for emergencies and “urgencies”, things that had a significant likelihood of worsening over a short period of time. While I hated to close my office and lay off my wonderful team, I did feel that it was the right thing to do. So I did.

In this brief post, I will review the current (as of June 11, 2020) guidelines put forth by the American Dental Association (ADA) and the Centers for Disease Control (CDC) and what dental offices are doing to safeguard the health of their patients, staff, and community. It’s important for people to know the risks associated with going to the dentist, to be able to weigh those risks with the risks inherent in delaying dental treatment, and what to look for to make sure their dental office is following the proper protocols for infection control, social distancing, and other safeguards.

Figure 1 (click to embiggen)

Risks

Until recently, most of us had never heard the term “social distancing”; now it is one of the guiding forces in our day-to-day lives. Giving wide swaths of space to others in the grocery store, the closure of businesses, and the elimination of concerts, sporting events, and other large gatherings is de rigueur. We feel naked if we venture out into public without wearing a mask, and washing our hands dozens of times of day has become the norm. We do not yet have a vaccine for SARS-CoV-2, and existing treatments for COVID are not much different than those employed during the Spanish Flu pandemic of a century ago, except they are fancier and more expensive. Until effective treatments and/or a vaccine are widely available, we have to rely on the above low tech measures as we have done since the times of the Black Death. It’s almost like the Miasma Theory of disease has made a comeback and we endeavor to avoid breathing the “toxic air” at all costs.

The problem with dental visits – for both the patient and the dental team – as it relates to the pandemic is pretty straightforward and obvious. Simply put, we are literally all up in your face. Social distancing is not an option. We can’t drill on your teeth via Zoom. Dentists, dental hygienists, and dental assistants are able to wear gloves, masks, and other PPE such as face shields, surgical gowns, and the like (when available), but patients have to present their bare faces to us, making them more vulnerable. For the dental team, the risks are heightened by the very nature of the work we do. Most dental procedures require some sort of mechanical treatment on teeth, i.e. drilling. During dental cleanings, hygienists often use ultrasonic scalers. Both of these treatments generate a fine aerosol, which is dispersed over a distance of up to several feet, depending on the layout of the room, ventilation, etc. Direct contact with saliva can be transmitted to other surfaces such as our overhead lights, drawer handles, and the like. The coronavirus can remain aerosolized for several minutes after a procedure is completed, and the virus can remain active and viable on solid surfaces for up to several hours, depending on the surface. The bottom line is that dental offices are places of high risk for disease transmission.

Before you freak out and cancel all of your upcoming dental appointments, let’s look at the flip side of the equation. Before COVID was even a thing, we dentists practice strict infection control, from autoclaving instruments, using single-use disposable materials whenever possible, employing rigorous disinfection practices between patients (e.g. wiping down all surfaces with bacterio- and virucidal wipes, covering chairs, light handles etc. with disposable wraps, and more), wearing gloves and masks, and other aseptic techniques. Transitioning to an enhanced system of disinfection and protection was an easy jump for us for the most part.

Resources

As I mentioned above, when the pandemic first hit the US in February and early March, dentists were unsure as to the appropriate steps to take. Fortunately, the CDC and the ADA were prompt with their information and guidelines. Trying to sift through new and sometimes contradictory data that was pouring in, the CDC and ADA kept us informed and updated on the current literature and the consensus advice on how to safely practice – balancing the health needs of the public with the risks inherent in dental care.

The CDC has consistently issued guidelines for dental practice reopenings, which is no easy task considering that each state has its own guidelines and different practice areas are at different risk levels (e.g. the risks for a dentist in downtown Manhattan are different from mine in Tonganoxie, KS). The ADA and affiliated state dental associations have likewise advised dentists on the best and safest practices, providing valuable educational resources (webinars, email updates, etc.), which are updated frequently. To see the statistics and guidelines for your state, the ADA has provided a handy interactive map to use.

On a more general note, I have often touted the excellent Center for Evidence Based Dentistry website, which is patient friendly and covers all areas of dentistry.

To this end, despite the higher risk level of dental procedures, there has not been a single reported case of COVID transmission from a dental office that I am aware of to date.

What can I expect?

So, if it is time for that overdue cleaning that you had to cancel in March, what can you expect when you go to your appointment? Every office will do things a little differently, of course, but in general you can expect the following precautions to be taken:

• You will be asked if you are experiencing any signs or symptoms of COVID (fever, cough, flu-like symptoms), if you have been exposed to someone with the disease, or if you have traveled to a “hot spot” where the infection rates are high.
• When you arrive at your appointment, you may be asked to wait in your car until it is time to be seen. You should wear a mask until a member of the dental team tells you to remove it.
• You may have your temperature taken and be asked to wash your hands or use a hand sanitizer.
• You may be asked to swish with a hydrogen peroxide-based mouthwash as a pre-procedural rinse to reduce the viral load in your saliva.
• Your dental care provider will likely appear as though she/he is preparing to enter the Chernobyl Nuclear Power Plant, garbed in gloves, high filtration mask, face shield, and gown or lab coat.
• Enhanced disinfection procedures – wiping down all surfaces throughout the office (not just in the operatories) on a regular basis, air purifiers, disinfection gadgets like UV light or disinfecting foggers may be employed.

If you are concerned about going to your dentist, please call them to discuss it. Some patients who are at a higher risk of infection – immunocompromised patients, elderly individuals, and those with other underlying medical conditions – might be advised to postpone any elective, non-emergency dental care. Sure, it’s important to have a sparkly smile, but if someone has an increased risk of illness, maybe that six month recall appointment can wait.

The future

No one knows what the future holds. Will there be a second (or third) wave? Will we be able to resume our normal activities in the near future? When will an effective vaccine be available? Your guess is as good as mine and no one has a crystal ball. What I do know is that the dental profession is committed to keeping you, our valued patients, safe and healthy. I know that sounds like an infomercial, but it’s true. Guidelines and recommendations are being updated continuously and dentists are unified in their desire to adhere to the safest practices in these unprecedented times.