Nothing Makes Dentistry More Fun Than a Respiratory Virus Causing a Global Pandemic and PPE Shortage!

By Laurene K. Duke, DDS

Uncertainty has been the mantra for me during these COVID times. I willingly shut my practice as the California governor asked us all to do in March. It seemed to be for only a few weeks. I usually take a vacation of 6-8 weeks per year and closing for a few weeks was not an issue for me. Since the stay at home order was in place, I did not travel (my planned trip was cancelled) and I could take this time to revamp a few protocols for aerosols and get back to seeing patients. WOW!! This was not the case as we all know. I did not even suggest my staff go on unemployment for the first few weeks, thinking it would be a short shut down and I could manage the payroll. So many unforeseen circumstances have led to these uncertain COVID times.

As the days and weeks wore on, I realized we were not going to open for regular business any time soon. I was at the office 7 days a week tending to the many day- to- day things needed when there was no staff. My staff said “governor has a stay at home order” we cannot even come to office!?

My days were filled with: Daily webinars which gave support and knowledge help to combat misinformation across all areas of media, how to handle team anxieties during this uncertain time, trying to get helpful information from the ADA and CDA, how to cover payroll, bills, upgrade costs, patient emergencies, not let the PPP loan application time out for the 5th time, working with increasingly needy patients, contacting, cancelling, and rescheduling 3 month’s worth of patients, working to keep the business solvent and the struggle of all struggles: successfully order proper PPE. Everything was uncertain.

Obtaining proper PPE was intensely stressful and unprecedented. We could barely get adequate supplies of PPE, and when we could order, the prices were outrageous and delivery times were lengthy. Our dental societies did not support us by helping obtain at normal prices --the needed , required PPE’s. The quality of many orders was inadequate for dentistry. I gave some boxes of those masks to my local beauty salon and police department who could get no PPE early on.

I am very grateful for the local CPA and HR firms who were really helpful as to if, when and how to fill out the complex PPP application ourselves. They gave continual daily encouragement to us – they were my emotional support during this emotional rollercoaster time.
Yet, stress was intensifing for me. The challenges of keeping my team and patients reassured –when I did not know the answers and trying to keep a positive attitude was overwhelming. I had to hold it all together for those that depend on me, even if my O2 levels went down to 82% during some early procedures before I started using EasyFlowUSA as my brain did not function normally. Learning how to handle team anxieties about the unknown future of our practice and health has added to my workload.

Employees with school age children have complicated matters as school schedules with online learning are in place for an uncertain amount of time. Mom needed to stay more involved with children at home and has to embrace their “teacher” roles. I have to give my RDA time to email and await answers during our workday when the counselor is responding. There are no more phone conversations with counselors in her school district- only frustrating emails - even as the student is missing half her senior year of scheduled classes. This time and stress impacts productivity and her emotional well being.

Another great financial concern was the costs to upgrade my older freestanding office to better handle aerosols to protect my patients and my staff. At this stage in my career, I was not planning on altering the “bones” of my office. Because of COVID, I had to rethink things. I added a device in my A/C unit to combat viruses and other aerosols. In upgrading my suction to a dry vac system to have better suction power in all 4 ops, I had to move the machines outside, upgrade the electrical system, hire a plumber to install new underbuilding pipes to handle the suction power, figure out logistics to alter my garden shed to accommodate the addition of a new tankless water heater mounted on the wall above the new Dry Vac and amalgam separator. So much money was spent – I appreciated the EIDL and PPP money I received. I am so thankful I purchased my little building in my first years of practice, so I have control over what I choose to do to improve my aerosols filtration.

There were many weeks of feeling completely let down by ADA and CDA as very little helpful information was being released. We contacted CDA in early May about why less contradictory information was not being released, they responded with “no association wants to be the first one to step out of the normal “. I am feeling as though dentistry has fought for 100+ years to be recognized as an essential part of mainstream medical care, and NOW the moment has arrived and our society just acquiesced to an uninformed government! This is terrible!! The ADA completely missed their moment In educating the government to keep dental practices open for all care. It makes me want to leave organized dentistry after all these years. I have been astounded at the lack of leadership. It has improved in August with the ADA president finally refuting the WHO guidelines. This is a bit too late for many practices to recover.

Dentists are a resilient group of people. I have made many positive safety changes over my 35+ years in practice. Some of these COVID changes will be an improvement and worth the extra costs to both the dentist and the patients, Many will be a waste of resources as we learn more about this virus.

The GEAR of Star Wars is better than being under a hot stuffy blanket all day, trying to breathe.

We have been practicing universal precautions since the 1990’s, and these protocols have kept us safe and comfortable. To my knowledge, no dental office has been the cause of any aerosol spread. With these new COVID regulations, many of us are reaching our breaking points in our new Star Wars space outfits. KN95 and N95 mask wear puts extra pressure on my mandible, and I get very sore joint and facial muscles. We are exhausted daily, go home with headaches from mask pressure and breathing inadequately all day. Before getting my EasyFlow device, my low oxygen environment was grueling during long appointments. I would have to step outside in my garden to get some full oxygenated breaths to feel better.

Wearing Level 3 masks, as we did for all these years, seems adequate given we have no transmissibility documented even in January and February when we now know the virus was in our communities. Level 3 masks did not cause head and jaw problems.. These tight masks and extended face shields make our necks and jaws hurt, along with creating extra eye strain from the glare of my loupe light on the shield. For all my years, I have enjoyed every day as a dentist in my small community, but now with donning and doffing this gear after every patient and dealing with all of the other struggles, that enjoyment is lost. It is so sad that I am ready to leave dentistry over these “protective” regulations that we may find are not even necessary.

Culture of Dentistry is fading
The culture of personalized care in dentistry has been changing since the advent of corporate offices. I value personalized complete health dentistry even though it takes more time and effort, and COVID has made achieving this so much more difficult.

We are less patient with our patients! Timing is now critical - exact patient times of entry and exit to allow for the aerosols to clear - is critical. I must not add an additional procedure to the mix if found during treatment, as it skews the timing too much. It upsets my business team’s’ logistics that they carefully formatted in scheduling the current day. My administrator is no longer tolerant of any “mishaps” in the schedule. Her stress level is even worse than mine. She used to calm us down, but now I calm her down, especially if I mess up the schedule with an additional filling or impression. However, these additions do help our struggling production.

Previously, accommodating our older patients was our specialty and much appreciated. Now when they need to go to the bathroom, I say, “Hold it! Let me finish!” I need to finish and get patients in/out in a more timely manner so the next patient can arrive to be socially distanced for my 3-4 patients a day (down from 8-10 per day). This timing stress leads to less time for enjoyable conversations with my patients.

We are seeing increasingly needy patients that “just call to talk” 5 times a week for 10+ minutes at a time. They are sad, lonely and worried about everything. Being so isolated, we are their safe social outlet. It is quite a stressor on each team member knowing we may be the only social outlet our patient has. So my team spends their precious minutes talking to them. When they decide to come in for their first journey out of their house in 4 months, our patients are very happy to see such careful attention to their safety.

Profitability is Still Needed!
My big question is HOW we are going to be profitable once PPP and HHS monies evaporate and we have to be self-sufficient again. I want to be an independent doctor as I always have been. 50% of my practice is cash. I bill insurance for my patients out of network. I am a provider for only Delta Premier -fee limiting! Delta Dental has been a thorn in our side for years. Now they are paying each exam at $10 extra for our expensive PPE changes. We can max bill for 2 exams per year so that is $20 more per year, if we are lucky enough to bill in their time frames. So Delta Dental is limiting their allowance to a non-aerosol generating procedure and not properly compensating dentists on procedures that do produce aerosols.

Fewer patients are coming in because of the increased infection control, costs, and social distancing, as well as those patients who are so anxious about COVID that they are delaying treatment. We are seeing much more emergent, difficult cases and complex cases– some on existing patients that have not been in for years and some on regular patients that are just falling apart from clenching, fracturing teeth or poor care in these times. I have seen so many fractured teeth these past few months– more than I saw all last year! Even my lab man says he is getting more complex crowns and bridges to complete since impressions are difficult because of increased subgingival decay. I was really surprised to hear his struggles with incoming lab work.

All of this adds up to less desire to be the owner dentist with all the headaches and none of the fulfillment we once had. I think we will see an exodus of doctors in their 60’s retiring in these uncertain times, whereas many dentists in the past retired in their 70-80’s. Private dental offices such as mine will evaporate when PPP monies are used up. We will be replaced by corporate models at an even faster pace than we have seen.


Team Angst
My small team of 4 all had different ideas on returning to the office. The human fear factor is one of the toughest obstacles through this pandemic, and I lost 2 team members. The news media and the hygiene societies saying that dental providers have the highest risk job was the clincher for them in leaving chairside dentistry.

When one RDA told me, “We cannot come ito the office for an outdoor meeting because we have to ‘stay at home’ per the CA governor’s mandate,” I was astounded. This meeting was to discuss protocols of safety going forward and to revamp the office. Things like taking away stuff on the counter and organizing the operatories that she will have to disinfect. We are aealthcare providers, and our patients need our care to stay healthy. My assistant chose to change careers and she is now selling dental equipment.

Having a healthy 57-year-old RDH retire because of health fears and bringing on 2 more RDH’s that require time to adjust to new COVID protocols plus joining our office that believes in a Total Wellness Dentistry program is both good and terribly draining, The month of May consisted of listening to and addressing team fears and combating the misinformation that has been taking over like a wild fire. Facebook and other social media was a terrible perpetuator of misinformation and fear.

Fortunately, at this rough time, an RDH incoming student who wanted “work experience” was referred by a patient. She has been a tremendous help as just an extra body to tend to the new protocols while we are teaching her about dentistry and Dentrix.
We are not as friendly and warm with the new additions– there is no extra time or money for social interaction, But we did enjoy delivered ceviche and margaritas while we social distanced in our outside garden one Friday. We do not eat together inside since lunches are staggered for social distancing. We need time to breathe without a mask on, and thus it must be alone or outside in our garden.

Now that we are scheduling patients in our new COVID style, we find it difficult to talk during procedures because we cannot hear each other with all the gear on, along with suctions and Easy Flow noise. Treatment time is not as enjoyable for patients, staff, or doctor.

Rethinking LASER Dentistry – COVID Style
Having two new hygienists with laser experience but without ALD certification or having used a pig jaw to learn on, I felt I needed to give them proper laser training so I hired my friend Gloria Monzon, RDH, of Advanced Laser Hygiene training. Since the mask and social distancing order was in place, we shifted the course to be an outdoor laser training on pig jaws in my office garden. And for the patient portion, we were able to have outdoor dentistry at my office (all the sliding glass door windows were open for great air circulation) while having a roof and electricity for the finer dental treatments. This is much like I did when on dental missions in Cambodia. At least, at my office, we have screens to keep bugs out and we can sterilize easily. We were productive and had a great time.

Laser Bacterial Reduction protocol has now been implemented BEFORE treatment for every hygiene patient and then if needed laser curettage during the appointment for periodontal patients. We feel research supports this method of reducing aerosols. We are using ReLeaf and or Isodry isolation/evacuation systems which are working well. We have confidence in our protocols and so do our patients. They are making and keeping appointments. There is no time to provide LBR on a weekly basis as we were doing PRE-COVID on certain patients. That 20 minimum appointment is not possible with the donning and doffing time needed. Patient care is not as ideal as it once was.

Dentistry has “Rolled Over”
Treating patients with and protecting ourselves from respiratory infections has been a part of dentistry forever. The graphic about “most at-risk” jobs for COVID listing dental clinicians as highest risk made the rounds for weeks; however it’s not a new or true graphic. Dental clinicians have always been at highest risk for respiratory-borne diseases, which is why our universal precautions exist. Just like with AIDS in the 80’s, let us assess our precautions, adjust as needed, and move forward caring for patients in safe environments.
In my operatories, we have the opportunity to open the large 8 foot sliding doors and quickly exchange room air during each procedure. We are leaving the windows open during the entire procedure– “Outdoor dentistry with a roof, and it’s high-tech!” This is now a new era in dentistry for all of us to navigate in our individual offices. I did not purchase an air purifier; I decided the large amount of cross ventilation possible from opening four 8 feet sliding glass doors was adequate to reduce aerosols in my 4 op office. But other dentists who do not have the luxury of having fresh air may consider air cleaners/purifiers.

Dentistry rolled over and shut up during this pandemic. We know our precautions work; research supports that. We know COVID preys on people with inflammatory diseases that are exacerbated by oral bacteria. Dentists know how to help minimize that and help patients be healthier. Yet, ADA was quiet. Many offices shut down, and even commercials were put out on how dangerous going to the dentist was. Nothing was refuted! This is simply not true.

All this fear mongering, without ever addressing how dentistry helps minimize urgent care visits or how dental care can increase overall health. This is a time in our lives and world when dentistry should be touted as a wonderful adjunct to medical care. EVERYONE should be going to a dentist who promotes wellness!

What Happened to Patient-Centered Practices?
Enough talking about our practice problems and issues because we should have a focus on our patients and how to care for them in this new era of a very infectious virus. Many people are off track with their hygiene because they are just off their own “personal schedule”. They have forgotten to brush and floss, etc. and many are snacking more. This leads to the increased periodontal issues which we are now treating in the interim with Perio Protect trays. Since I treat many older folks, I am seeing much more interproximal gum line decay and Incisal tip decay from pH imbalances and food debris collecting.

Specialists initially were very hesitant to see any referrals– questioning “how much pain the patient was in,” and if it was not a level 7 or greater, many of my specialists would not see the patient. Now that they are seeing our patients, we need to talk about care on the phone which is a real disrupter to aerosols containment. It seems as soon as I get all “gowned up” like a Star Wars character to start treatment on my current patient, the call comes and I need to talk. So I need to make a quick decision: do I doff everything or take the call in my gear and risk aerosol contamination? The question, “What will my schedule allow?” runs through my mind. This is an unplanned moment and becomes very stressful as my staff glares at me and says with her exposed eyes, “Don’t mess the schedule up again!” I feel the doctor and administrator are adversarial in these uncertain COVID times. The doctor wants patient care, and the staff want timeliness above all else to keep the entire office “safe”.

Staffing Changes Have Been Drastic.
Many of us have new additional roles of laundress and temperature-takers as we are still trying to be supportive of our team who have childcare issues or fears.

The current staff I have cultivated are all very positive and careful. I am thankful! I have spent many hours researching, watching webinars, and then educating them about all the safety precautions that are in place as usual– with a few additions. Our RDA, who is normally so amazing and forward thinking, was frozen, she was very worried through all of this planning. But now that she is back full time, she has embraced our changes. She feels safe in her bouffant and confident with her Easy Flow device supplying air to her KN95 mask.

It is slowly dawning on my team and others that we HAVE been using universal precautions for 20+ years, and it works. We as a profession should be proud that there has been no documented dental transmission of respiratory illness that I know of.

At this stage in my career I could retire. I could go teach and leave chairside dentistry. I could do a lot of things with my years of experience but I LOVE being a restorative wellness dentist.

As a doctor who knows and treats whole body wellness via the oral systemic connection, I felt totally pushed aside during these COVID times. My state shut down, my team followed the rules, and I was left with no team to help my patients. I saw few patients from March 15 - May 29, and then I worked mostly alone for 30 days. My RDA came back half time in June, but the extra unemployment money kept her at home with her baby. Supporting patients health via periodontal care to reduce whole body inflammation was not possible with no staff.
I used to love my career of 35+ years in dentistry–never wanted to retire– just wanted to phase out and let someone “phase in” while I mentor her a bit giving her a good foundation to go forth. With the stress of timeliness while wearing various masks, airflow devices, loupes, clips, shields and trying to change gowns between patients, I get all wrapped up in the cords and am ready to just quit!

It is increasingly more difficult to remember what I love about this job and field. That is how COVID has affected me.

My Bright Spot - Easy Flow!
My business administrator and I in our small office of 4 employees have been working tirelessly since April and, now by August, the emotional toll is catching up after 6 weeks of working in a full “new-normal” schedule and being sick from lack of O2 after every major procedure with KN95 or N95 masks. Oxygen levels dropping to 83, 93, and 94 during treatment is the worst feeling a clinician can have. THEN, we found Easy Flow USA!! This has been the best addition to our PPE as it allows for long appointments, easier airflow, and breathing while wearing KN95 or N95 masks. Days end again., with a smile.

Increased camaraderie between dentists during these challenging times has been a wonderful way to reconnect with long ago classmates across the state and nation. All the great continuing education and webinars put on for free for us have been heart warming and somewhat helpful. It was a great morale booster to hear from others in real time on various Zoom meetings.

Yet, the response from ADA, CDA, our insurance carriers, and agents have been dismal and disheartening. These associations have really been no help at all in my office locale. ADA puts out contradictory statements and seems supportive of only corporate dentistry– ignoring the fact many private dentists like myself can do “outdoor dentistry” and treat our patients safely in a low aerosol environment. Corporate offices and those in bigger buildings have a more difficult task to clear the aerosols. CDA has sadly just followed ADA rulings. Yet many of us think each office should be able to decide what is safe for their locale. We are healthcare providers and we should be treated as such! No medical offices closed during these COVID times.

I felt many dental offices could have stayed open this entire time, with aerosol precautions in place, treating our patients desiring care. This would have kept my team employed and off unemployment. Once on unemployment, they did not want to come back. They found it more profitable to stay home, receive unemployment benefits that exceeded their usual wages, and not pay for childcare or gas to get to office. It became much more profitable to just stay home. My team only wanted to work part time in order to receive the extra $600 benefit. Finally, full time employees are back since the benefit disappeared as of July 31st. I hope this type of “aid” does not happen again as it was detrimental to small healthcare offices.

No matter how hard I try to guide my practice, sometimes I feel as if I am just a “whisp in the winds of change” during these uncertain times.


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