Coronavirus Impact on Dental Service Providers

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Coronavirus Impact on Dental Service Providers

The dental industry is facing many coronavirus-related challenges from staffer incomes and procedural reimbursements to patient and community health and safety needs. In many respects, the coronavirus crisis is too new for effective analysis specific to the dental industry. Still, the research team was able to find that dentists are expected to lose ~90% of their cases during the next month due to the considered ban on elective procedures. The team also analyzed dental practice guidelines, business best practices, and overviews of consumers and the dental industry. Full details are available below.

I. Dental Health Provider Coronavirus-Related Challenges

CHALLENGE #1: Postponing Elective Procedures Slashes Incomes

  • In California, dentists are being asked to voluntarily suspend non-urgent and non-emergency dental care for the next 14 days (starting March 16, 2020).
  • The American Dental Association (ADA), via a March 16th statement, recommended that dentists nationwide postpone elective procedures for the next 3 weeks.
  • The American Dental Hygienist Association (ADHA) also noted to consider postponing all non-emergency and elective dental procedures. But the letter from the ADHA specified to postpone procedures “in patients who have signs or symptoms of respiratory illness.”
  • As early as 2001, the general health of the average person’s teeth (due to fluoridated water) dictated that many dentists earn their incomes largely from elective procedures. Some even estimated that 50% of a dentist’s income was from cosmic work.
  • Even if using those figures as a rough estimate, dentists could lose almost 50% of their salary should they follow the ADA’s recommendation to stop all non-emergency work for the next 3 weeks. Others estimate the figure might be more like 90% of dental work.
  • One dental office, High Point Dentistry, serving Elgin, Palatine and Schaumburg in Illinois, reports to have ceased elective procedures like cleanings, implants, and veneers and are now only seeing patients who have swelling, pain, abscesses/draining, or trouble closing their mouths.
  • The California KiDDS Pediatric Dentistry locations are effecting changes that impact 55 staffers and 37,000 patients. The basic changes include triages over the phone first, emergency procedures only, and thorough cleaning and sanitization.
  • One source suggested that dental offices participate in medical billing to boost revenue noting that about “70% of the procedures that may be billable to medical are procedures that dentists are already doing in their practice, such as exams, implants, bone grafting, extractions, etc.”

CHALLENGE #2: Recommendations Require Additional Policies

  • Now that the ADA and various other state chapters, and other dental professional organizations have issued recommendations about limiting the spread of COVID-19 by limiting elective procedures in dental practices, dentists are faced with new questions and needs relating to the new recommendations.
  • For instance, as noted by a representative of DecisonOne Dental Partners, dental providers need a proactive plan on just how to adjust their practices for coronavirus infection prevention.
  • Dentists are also said to need guidance on which essential dental services need to be monitored more closely due to increased likelihood of becoming emergencies if left untreated. Some dentists are noting that “emergency extractions, root canals, and chipped teeth that could cut a lip are seen immediately.”
  • Dental professionals also need well-defined plans on how to care for COVID-19 patients while they are having a dental emergency.
  • One large dental network in Illinois and Wisconsin proactively engaged state and federal authorities on its needs and advised dental practices to think through a list of essential, non-essential, and potentially essential services as they await additional guidance from state leadership. This particular dental network decided to have select locations open for 3 hours per week for dental professionals choosing to work. Those who were not comfortable working, immunocompromised, caring for the elderly, or had any other issue that made them more susceptible to COVID-19 severities were not allowed to work.
  • The New Mexico Dental Association is notifying patients to call their dentist should they have tooth pain, swelling, or difficulty eating.

CHALLENGE #3: Shortage of Gloves and Masks

  • As an example of the effect this shortage has on the dental profession, a look at this video reveals one dental office worker reporting that not having masks or gloves in stock and her practice “is being charged 3x the price, suppliers are low in stock, this is scary to people that work directly with spit, saliva, and blood.” She is asking consumers to leave these items for medical workers, especially dentists since this industry is currently feeling the shortage affects intensely.
  • A news report out of Youngstown, Ohio noted that a local dentist, who had yet to be notified of any shortages, had just received word that his supplier was running short on masks.
  • These shortages experienced by local dentists were already projected through the earlier and current experience of hospital providers.
  • An additional unknown throughout all of this is that no authority has been able to say how long these limited provisions are going to be in place.
  • The CDC urges that, at this time, dental health providers concerned with health-care supply issues monitor the Healthcare Supply of Personal Protective Equipment resourcefor necessary guidance.
  • The CDC also notes that limiting elective services will be an aid in rationing medical supplies.
  • A local news channel in Elizabethtown, Kentucky reports that one dental office couldn’t order the supplies needed and would be limiting procedures to save on supplies and reduce the risk of infection in their community.

II. Best Practices (Minimizing COVID-19 Spread/Infection)

CDC Guidance

  • The CDC Division of Oral Health, as of March 10, 2020, is still in the process of developing specific guidance for responding to COVID-19 in dental settings.
  • For the time being, the office notes to delay all elective procedures and routine exams to preserve staff safety/health and medical supplies.

Guidance From the Journal of Dental Research

  • The dental industry is lacking consensus on the role of dental services during epidemics. Researchers experienced with SARS in the dental field suggested that dentists “take strict personal protection measures and avoid or minimize operations that can produce droplets or aerosols.”
  • Because patient blood, secretions, and saliva can become aerosolized in dental settings, "the standard protective measures in daily clinical work are not effective enough to prevent the spread of COVID-19, especially when patients are in the incubation period, are unaware they are infected or choose to conceal their infection."
  • Hand hygiene is considered the most critical measure for reducing the transmission of microorganisms from person-to-person.
  • Personal protective equipment (e.g., masks, gloves, gowns, and goggles or face shields) is recommended to prevent all routes of infection.
  • Particulate respirators “(e.g., N-95 masks authenticated by the National Institute for Occupational Safety and Health or FFP2-standard masks set by the European Union)” are the top of respirators recommended for routine dental practice.
  • The 4-handed technique is also reported to be a good technique to use to control infection as are “saliva ejectors with low or high volume to reduce the production of droplets and aerosols.”
  • Dental clinics are also encouraged to establish precheck triages for checking patient and staff temperatures (high temperatures are reported/referred to hospitals), all persons in the office should be provided with medical masks; in areas where COVID-19 is spreading all nonemergency dental practices are recommended to be postponed.
  • Dentists might also consider having patients rinse with a preoperative antimicrobial mouth rinse. Other dental offices are requiring that patients rinse for 60 seconds with 1% hydrogen peroxide before all treatment.
  • Dentists are encouraged to avoid all aerosolizing activities (e.g., 3-way syringe, intramural x-ray). Dentists are encouraged to use extraoral dental radiographies like cone beam CT or panorama radiography to help reduce the likelihood of coughing/producing droplets.
  • The use of rubber dams and high-volume saliva ejectors can also help minimize droplets and spatter. The report makes additional detailed recommendations and suggestions to avoid splatter, aerosols, and infection.

Guidance From The American Association of Endodontists

  • The American Association of Endodontists (AAE) recently published COVID-19 implications for clinical dental care. Included in this recently published journal article are guidelines for providers in the dental care setting for patient management and prevention of nosocomial infection.
  • The AAE proposes that telescreening be an important part of patient triage. This initial patient screening can be done via phone during appointment setting. Initial screening includes questions related to travel and feelings of illness. If offices also track community infections through dashboards (like the one by Johns Hopkins University) patients who are turned away (to wait for an incubation period that can range from 0-24 days) should be encouraged to self-quarantine if in areas of high infection risk.
  • Patients that qualify for an appointment should be provided with a COVID-19 screening questionnaire and an “assessment of a true emergency questionnaire” at check-in.
  • Patient temperature should be checked with a non-contact forehead thermometer (or with infrared thermal sensor). For people with fevers and/or respiratory illness, the appointment should be postponed for 2-3 weeks. Also, according to the CDC patients suspected of COVID-19 should be “seated in a separate, well-ventilated waiting area at least 6 feet from the unaffected patients seeking care.”
  • In the unlikely event that a dentist must treat a patient with active COVID-19, dentists “should follow the standard, contact, and airborne precautions” as well as additional procedures. While the recommendations are listed here, it should be noted that “patients with suspected or confirmed COVID-19 infection should not be treated in a routine dental practice setting.”

Specific Examples

  • The High Point Dentistry office in Illinois has waived cancellation fees and is asking patients who have traveled or are not feeling well to reset their appointments.
  • Other dental offices have made isodry isolation mandatory for all procedures except endodontic procedures and third molar extractions (including all hygiene procedures).
  • An added caveat to some policies is to limit new patients (e.g., the Penn Dental Medicine Family Practice are seeing emergencies only and only for patients of record).

III. Best Practices (Business Response to Consumer Behavior Shifts)

Be Flexible & Apply Lessons Learned

  • Beyond mitigating the effects of COVID-19 prevention and infection, additional business-related best practices for dental offices wanting to deal with and prepare for customer behavior shifts and provide value during and through the COVID-19 outbreak was put together by Harvard Business Review; “12 lessons for responding to unfolding events, communicating, and extracting and applying learnings” is based on a current analysis of its global clients. These lessons include maintaining daily updates of self/team/customers, thinking critically about news reports, and being willing to have a “best current view” on understanding the status of the coronavirus crisis.
  • An eye clinic in Illinois, in an effort to avoid spreading infection and in response to the best available options for mitigating the spread of disease, has asked patients who have come in for emergencies or necessary surgeries, to wait in their cars rather than the waiting room within the office.
  • In response to these guidelines as well as calls by dental professional authorities to cancel all elective procedures, some dental schools with clinics have completely closed. Others have decided to only admit emergency-based cases and “some are offering additional screening protocol guidance based on federal agencies’ guidelines.” Many schools have canceled elective appointments through March 30, 2020.
  • Other school clinics added protocols to reduce transmission like asking sick patients to reschedule and reviewing patient travel histories. Sick staff is asked to self-quarantine without penalty.
  • A dental office in Edmond, Oklahoma has already begun written communications to patients, as a letter to patients states that the office will increase cleaning and sanitation. The office has also discontinued the waiting room. To further facilitate transmission prevention, all clinical and business functions are set to occur in the treatment room. Also, other than parents with children, all other guests are not welcome into the office. This office has also minimized contact with doors (front door is propped open).

Consider Mobile Dentistry

  • The COVID-19 outbreak has some dentists thinking differently about mobile dentistry since many potential patients (even after the crisis subsides) may be unwilling or uncomfortable sitting in waiting rooms or encountering traditional health facilities.
  • The Organization for Safety, Asepsis, and Prevention put together a guide based on CDC guidelines. The guided checklist is called “Infection Control Checklist for Dental Settings Using Mobile Vans or Portable Dental Equipment” and includes mobile dental clinic infection control actions such as those related to water supply, reusable patient items, medical waste, and housekeeping.

Investigate the Feasibility of Teledentistry

  • There is a noted need for 5G technology in response to more things being done remotely and an increased reliance on telemedicine.
  • Insurance providers like Blue Cross Blue Shield are increasing “access to prescription drugs, enhanced telehealth, and other clinical support systems to combat the spread of COVID-19.” Regarding telehealth, BCBS expanded access to telehealth and nurse-provider hotlines.
  • While it may be a bit early in the crisis for any dental office that had not previously set up telehealth protocols and technologies to now have them, dental providers should know that 78% of patients believe they are likely to use this type of service within the next 5 years.
  • Working people were noted as the group who would most benefit from teledentistry. Further, a study in Australia found that detecting cavities via smartphone cameras and other imaging apps was reliable. Should social-distancing remain a long-term aspect of consumer behavior change due to COVID-19, it increases the opportunity that dentists have in establishing teledentistry within their practices.
  • Further support of telemedicine during the COVID-19 outbreak within the US is illustrated in the fact that the Office for Civil Rights (OCR) at the Department of Health and Human Services notified the public that, effective immediately, it would exercise discretion in enforcing certain HIPAA Rules for “covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency.” The OCR has especially instituted this discretion because some of the technologies to be used by covered health care providers and the way the technologies are used may not be fully compliant with requirements within HIPAA Rules.
  • Likewise, the American Association of Dental Boards recently (March 17, 2020) issued its first telehealth directive for its member dental boards “touting the necessity for accessible care through teledentistry.”
  • Another example pointing to the use of teledentistry leveraged during this coronavirus outbreak is that Dentulu, a leading telehealth service for dentistry in California is “opening up its platform to all dental professionals as well as hospitals across the US.”
  • The Dentulu service provides intraoral cameras to patients via mail service or pick-up. ERs in Los Angeles are encouraged to contact the Dentulu Network for dental patients’ needs.

IV. Impact on Dental Health and the Dental Industry

COVID-19 Impact on Dental Health

  • Some dentists recommend that dental patients continue to address dental infections or issues because untreated concerns can often weaken the immune system and leave one more susceptible to COVID-19.
  • Once inside the human body, this current coronavirus (SARS-CoV-2) is “abundantly present in nasopharyngeal and salivary secretions of affected patients and its spread is predominantly thought to be respiratory droplet/contact in nature.”
  • As late as March 18, 2020, WHO and the British Medical Journal recommended the use of “acetaminophen for analgesia and not ibuprofen in treating COVID-19 infected patients, as ibuprofen may interfere with immune function.”

COVID-19 Impact on the Dental Industry

  • The dental industry appears to have had to step up on self-advocacy recently as it discovered (in the US and abroad) that governments were needing specific prodding to guide dentists in the treatment of patients with and without COVID-19. On March 12, 2020, the ADA sent a letter to State Homeland Security and Governmental Affairs Committee Chair Ron Johnson, R-Wis., and Ranking Member Gary Peters, D-Mich. The letter stressed that dentists are also primary care doctors and require congressional guidance and protection (especially related to personal protective equipment supplies).
  • A recent study reviewed the most “at-risk” occupational environments when it comes to health (exposure to infection/disease, contaminants, hazardous conditions, radiation, and minor burns/stings/cuts/bites) and dental positions took 4 of the top 5 spots (i.e., dental hygienists, general dentists, veterinary assistants/laboratory animal caretakers, dental laboratory technicians, and dental assistants, respectively).
  • Dentists are expected to see a 90% drop in services/number of patients (2/day from 20/day) due to COVID-19 infection control procedures.
  • Dental offices estimated to usually have $100,000 per month in cash flow are now expected to receive only $3,000.
  • Other segments of the dental industry are also vulnerable to changes brought on by the virus outbreak. For instance, Align, the company that sells Invisalign, is expected to sell 20,000-25,000 fewer cases during the first quarter of 2020.

V. The Public’s Reaction to COVID-19

Consumer Behavior Thresholds of COVID-19 Concern

  • Consumer behavior connected to the COVID-19 outbreak response has been outlined by Nielsen. As COVID-19 passes certain event markers, so too do consumers cross certain behavior thresholds. For instance, when a community’s first localized transmission happens (as an event marker), this marks the time that customers will “prioritize buying products essential to virus containment” like face masks.
  • Once consumers get back to life, they may find themselves “living a new normal.” They are expected to have a “renewed cautiousness about health.” Dental offices should also expect permanent changes regarding supply chain shifts, e-commerce, and basic hygiene practices.
  • According to Nielsen, China is the only world region that is currently moving into level #6 (living a new normal after restricted living). Nearly one month after the virus peaked in the country normal shopping patterns are returning. However, experts feel that “some long-time purchasing habits may be permanently changed.”
  • “There is an emergence of a new retail environment. Consumers who might have been hesitant to embrace online shopping previously, older generation consumers or for fresh purchases, have now trialed it and experienced the benefits so will unlikely revert to their old patterns.” (Ryan Zhou, Vice President CPG, Nielsen Connect China)

Responding to Consumers’ COVID-19 Concerns

  • Businesses affected by COVID-19 are advised to keep consistent management of stock levels on health-safety products such as hand sanitizers and masks since these items are particularly sensitive to times when consumers may be in the “pantry preparation” mode of response to COVID-19 news/events.
  • Nielsen also suggests preparing for supply chain bottlenecks or hiccups especially in countries that have experienced mass outbreaks.
  • Also, according to Nielsen, businesses that can leverage technology to get customers what they need through digital connectivity (augmented/virtual realities, online services/shopping) are not only able to seize this current opportunity where consumers are more likely to seek online and digital solutions but they also have an “opportunity to earn consumer loyalty well after consumers’ concerns subside.”
  • Dental consumers, just like general consumers, are bound to seek assurances about product quality and risk-free status. In this type of environment, it might be essential for “manufacturers, retailers and other related industry players to clearly communicate why their products and supply chains should be trusted.”
  • Consumers tend to prefer to shop locally or home-country-specific. So many regional businesses would be wise to consider emphasizing any local features of their supply chain as a way to meet the transparency around supply chain and distribution likely to be of interest to many consumers during and after this coronavirus crisis.
  • Nielsen found that because more families are working and interacting remotely during the COVID-19 crisis, digital media is especially consumed at higher levels.

Research Strategy

It appears that published best practices on dental practices that have weathered the storm of the coronavirus and its lessons learned and/or best practices were not available likely because the current status of documentation, processing, and debriefing about solutions is fast-paced and ever-evolving in the current coronavirus climate. However, in order to identify best practices, the research team identified CDC-based general pandemic guidelines, research from relevant professional groups, and general health-related business reports based on serving patients during pandemics and/or the coronavirus crisis.

Please also note that the team reviewed countless news articles, academic reports, and COVID-19 information warehouses but was only able to locate very limited information about the current coronavirus and its impact on dental health and the dental industry as a whole. To provide useful details, we have slightly pivoted and included details related to general consumers.

The research team also thoroughly looked for analyses about dental or healthcare patient reactions, challenges, and pain points during times of outbreaks. Currently, this type of discussion/analysis does not seem to be available online. This is likely due to the current stage the US is in regarding fighting COVID-19. Because the dental industry is just beginning to be impacted, there are not that many reports that offer broad analysis. In these cases, the team has used coronavirus-related consumer analysis for retail products to approximate what may be valuable for the dental industry.