The Challenges of Pandemic Dental Care

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On March 20, when Gov. Andrew M. Cuomo of New York ordered nonessential businesses closed, a colorful sign appeared in the window of my dentist’s office. It reads, “We are still here for you! Call our office if you are having dental pain or an emergency.”

Like so many others, Dr. Edward Lee, a general dentist, and his brother and partner, Dr. Richard Lee, an orthodontist, have been unable to serve their non-urgent patients during the Covid-enforced closures put in place to flatten the soaring curve of the pandemic in New York. In addition to their young families, they support an office staff of 13.

“We had to furlough all but two members of the staff, leaving the rest to depend on unemployment insurance, or there wouldn’t be a business for them to return to when we could reopen,” Dr. Edward Lee told me.

His main frustration: “Every stage of dental care has a level of urgency. Problems that were put off can flare up. If patients are in pain, it’s already too late. Yet while podiatry offices were allowed to remain open, people were told it’s OK not to see the dentist right now.”

While certain issues can be discussed with dentists over the phone and remedies recommended, dental care is generally less amenable to telehealth visits than regular medical care.

Patients like me needing routine or non-urgent care, like a semiannual cleaning or a crown to complete an implant procedure, have had to wait until restrictions were lifted for my dentist to provide the up-close-and-personal care I require.

In the meantime, like many other dentists, the Drs. Lee have upgraded their already high-end dental equipment and mapped out enhanced safety practices that they expect to maintain indefinitely.

“Covid-19 is not going away anytime soon, and these measures can help protect us and our patients from anything else that might come along in the future,” Dr. Lee said. “We have to behave as if this virus will always exist. This is the new normal.”

Actually, even without the additional protective measures these dentists have installed after the pandemic struck New York with force, the risk to me in their immaculate facility would have been minimal. In a properly maintained dental office, practitioners are at higher risk of infection than patients.

“We always did a lot with respect to personal protective equipment and keeping the office clean, and now we’re tweaking what we already did to be even safer,” Dr. Lee said. After every patient, all surfaces in the treatment room are wiped down with a chemical that kills viruses within one minute. To clean instruments, a top-of-the line autoclave is used that first sucks all the air and liquid out of instruments, then sterilizes them with high heat and pressure before drying them completely to minimize the risk of recontamination.

On May 20, the Centers for Disease Control and Prevention issued updated guidelines for dentists preparing to resume nonemergency dental care that include recommendations for treating those with Covid-19 as well as those without the virus. Such strategies are important because no test is 100 percent accurate. There have been many false-negatives for Covid-19 virus, so even if I tested negative the day before coming to the office, it would not guarantee that I don’t have the virus.

Dental procedures are especially challenging because many involve the use of high-pressure sprays of water and air that could disperse virus-containing aerosols from a patient into the treatment room. Dr. Lee knows people worry about aerosols, which is why the office has installed HEPA filtration to keep the air cleansed and moving. The dentists are now also using a special device to control aerosols that are unavoidable during dental procedures. For practitioner protection against aerosols, the dental hygienists now wear face shields when cleaning teeth, as will the dentists under certain circumstances.

The Drs. Lee are also taking further steps to protect both their workers and the workers’ families from Covid-19. All employees wear masks, gloves and gowns, and at the end of the workday, these are left at the office and cleaned.

Still, these dentists are among many others worried about the risks to patients who postponed dental care during imposed Covid lockdowns. A patient who in January may have had a cavity that could have been addressed with a simple filling may now have a much larger area of decay that requires a more costly and involved root canal or even removal of the tooth and an implant.

  • Frequently Asked Questions and Advice

    Updated June 5, 2020

    • How many people have lost their jobs due to coronavirus in the U.S.?

      The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.

    • Will protests set off a second viral wave of coronavirus?

      Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.

    • How do we start exercising again without hurting ourselves after months of lockdown?

      Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.

    • My state is reopening. Is it safe to go out?

      States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

    • What’s the risk of catching coronavirus from a surface?

      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

    • How can I protect myself while flying?

      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • Should I wear a mask?

      The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

Patients who had had a tooth pulled and were ready to get an implant when the pandemic struck and dental offices closed could have lost enough bone during the delay to impair the success of implant surgery. Or if, as in my case, the implant was already in place but the usual months of healing had passed and the patient was awaiting placement of a crown, the surrounding teeth could have shifted toward the empty space, leaving insufficient room for the false tooth.

I now understand why a friend’s dental surgeon advised him to have an implant done while Covid-19 infections peaked in New York City. The procedure, my friend said, was done with extraordinary attention to safety and all went well.

A treatment delay during the dental lockdown is potentially even more serious for those with moderate or severe periodontal disease, which afflicts one in 20 adults aged 20 to 64.

Gum infections cause body-wide inflammation that raises the risk of developing heart disease and diabetes, both of which in turn increase the risk of acquiring a life-threatening coronavirus infection. In fact, inflammation alone is a risk factor for developing Covid-19.

For young orthodontic patients, Dr. Lee said, “timing is everything. More aggressive treatment may be needed if treatment is postponed. Pediatric patients could age out of treatment and may need surgery in the future as an adult,” he said.

He added, “Personally, I was comfortable with opening up in early May but waited until the governor gave his OK. We deal with infection control on a routine basis. This is nothing new for us.”

Both in the dentist’s office and elsewhere, there is still another important safety issue that concerns everyone, especially people who already had Covid-19 and recovered and those who are tested and shown to have antibodies to this coronavirus. Neither a prior infection nor the presence of antibodies guarantees protection against a new Covid infection. It is not yet known how many antibodies are needed to prevent it, how potent the antibodies have to be or how long their protection may last. These are the same as-yet unanswered concerns surrounding the effectiveness of any future vaccine.