The challenges of pandemic dental care

Jane E. Brody, The New York Times

Posted at Jun 09 2020 07:41 AM | Updated as of Jun 09 2020 10:40 AM

The challenges of pandemic dental care 1
Even without the additional protective measures dentists have installed after the pandemic struck New York with force, the risk to patients in their immaculate facility would have been minimal. Gracia Lam, The New York Times

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 Lees 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,” 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,” 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 re-contamination. 

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. 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 Lees 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.

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, 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.

Editor Notes: Jane Brody is the personal health columnist at The New York Times, a position she has held since 1976. She has written more than a dozen books including the bestsellers “Jane Brody’s Nutrition Book” and “Jane Brody’s Good Food Book.” 

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