On May 31, New York Governor Andrew Cuomo said that dentists could begin offering elective and other non-emergency treatment, beginning June 1. After more than two months, dentists in the Empire State were among the last in the nation to get their state’s approval to resume care, though they will still be subject to guidance on safety and social distancing.
“We have gone through hell and back. We are on the other side and it’s a lesson for all of us, and we need to stay vigilant as we reopen different parts of the state so that we don’t backslide,” said Cuomo. “I am also authorizing dentists to resume their practices statewide starting tomorrow as long as they follow health and safety guidelines that the state is laying out and that we have been discussing with them.”
Boots on the Ground
Periodontist Jay Rubin, DMD, has mixed feelings about the news.
“Today was the first day back as per New York State guidelines. Part of me wanted to be happy and sing like the Seven Dwarves from Snow White, going back to work. But there is a lot of anxiety, so I decided to go back with a soft opening,” Rubin said.
“I worked half a day and had my hygienist come in today to make appointments starting tomorrow. Previously, they all started at 8:30. Now I have them start at staggering times. One at 8:30, one at 9 am, and one at 10:15,” he said.
“My associates will also work at staggering times so our patients will be seen at different times. A lot to work out still. It’s tough,” he said.
Rubin has been in private practice in Brooklyn since 1990. As the senior partner there, he works with two other partners and four hygienists in a staff of about 15. Since Cuomo’s March 20 executive order limiting treatment to urgent care, he and his staff have only been seeing emergency patients.
“I had a patient who fell down a flight of stairs and fractured a tooth. That’s an emergency. The patient came in, and I had to remove the tooth. I’ve had patients with swelling that needed an incision, drainage, and an antibiotic. I’ve had patients with large cavities that needed a root canal. I referred them to a root canal specialist. I would put them on antibiotics,” Rubin said.
Rubin’s team cancelled all other appointments and set up a master list of patients to call back once full operations are underway. Only one doctor, one assistant, and one receptionist have been reporting to the office for about half a day each day, seeing about one emergency patient each hour.
There were multiple obstacles during the shutdown. For example, some of Rubin’s patients struggle with excessive bleeding because of blood thinners they need to take. These patients need to see their doctors to manage their medication before seeking dental treatment, but in many cases, those doctors’ offices weren’t open.
Various shifting guidelines were another challenge.
“Information is changing constantly. The hard part is to go through that information and determine exactly what information is clinically relevant with scientific-based evidence, versus fake news,” Rubin said. It’s such an evolving situation. But we need people to step up and say ‘Hey, this is what we know.”
Rubin says that the ADA’s interim guidance toolkit has been very helpful in helping practices operate safely and effectively. He also says he’s a member of a WhatsApp group called Corona Dentists that has been essential in providing news about a range of topics, including personal protective equipment (PPE), the Paycheck Protection Program (PPP), and more.
Also, Rubin is cautious but not afraid of potential infection risks when it comes to COVID-19. Dentistry has been managing patients with infectious disease such as HIV and hepatitis since the 1980s, he said.
“We’ve always been comfortable treating patients with HIV, and I’ve always been comfortable because I use universal precautions. I assume everybody should be treated the same way. So it doesn’t matter to me what the patient has,” he said. “Dentists are notoriously ahead of the game in managing these kinds of environments. I think dentists have really been on top of this COVID situation.”
The New Normal
Rubin’s practice uses now familiar infection control procedures. Plexiglass has been installed in the waiting room. Magazines and other materials have been removed. Patients fill out a questionnaire and get their temperatures taken upon arrival. Social distancing is an issue, though, so visitors should come by themselves or with no more than one other person.
“In New York, space is tight. No one is having six feet of separation in their waiting room. If you have two people there, that’s 12 feet. Impossible in New York City offices,” he said.
Unlike practices elsewhere, there are no adjacent parking lots where patients can wait to be called into the office. Plus, patients and staff alike use mass transit in New York City, increasing the potential for exposure.
“That’s a fearsome anxiety problem unto itself,” Rubin said, making the practice’s reliance on pre-screening even more vital. Of course, he and his staff rely on proper PPE use as well.
“I’m wearing scrubs, a disposable gown, an N95 mask, a Level 3 mask, a shield, a head covering, bootie coverings, and gloves,” he said. “You should see me after an hour with a patient. Twenty minutes with a patient. I’m sweating like a pig. Literally. I know the N95 is working. You know how I know? I can’t breathe.”
Plus, each room in the office has HEPA filters and air purifiers that remove 99.9% of particles, he said. The practice also tries to minimize its use of Cavitron and piezo units to minimize aerosol production. It uses one low-speed and two high-speed suction systems with each patient as well. After each procedure, the room is sprayed and wiped down and allowed to sit and dry. While one room is drying, another is used for the next patient.
“The turnover used to be higher. Much higher,” he said.
Rubin’s chief fear is that patients who haven’t been able to get routine care could see their oral health deteriorate to the point where emergency care would be necessary, making New York’s reopening even more welcome news.
“A patient came to my office today by ambulance with a tracheotomy and COVID-19, with antigens already. I spoke to the pulmonologist. I said, ‘Listen, before she comes to my office, I need to know that she’s cleared for treatment and that she’s okay,’” Rubin said.
“Five people were helping her in a gurney with portable oxygen and portable machines. She had an implant-supported prosthesis that had moved and was cutting her cheek. Now she had this tremendous ulceration and excruciating pain,” he said.
“This is a 92-year-old lady. This is generally a routine procedure, but now it’s become an emergency because more and more as time goes on, routine procedures that were delayed for a few weeks now are becoming a few months and turning into emergencies,” Rubin said.
Rubin’s other chief concern is the lack of personal communication with his patients. New patients have no idea what he looks like under all that gear, which makes a difference in establishing trust. So, he goes out of his way before the patient comes into the office.
“I try to speak to them before the appointment myself. I call them generally and I introduce myself. ‘Hi, it’s Dr. Rubin. I know you’re coming in. Tell me what’s going on. How can I help you?’” he said, adding that the new world has created “a more sterile environment from a virologic and biological standpoint, but also from an emotional standpoint.”
Looking Ahead
Rubin also is the director of implant dentistry at the Touro College for Dental Medicine. He teaches Intro to Implant Dentistry for second year students, a treatment planning and surgical seminar for third year students, and Advanced Implant Case Review for fourth year students. These students have been learning remotely, though.
“I’m texting and WhatsApping my students about CE classes, about courses, about their anxiety about going into the real world,” he said. “Here you spend four years really working had and really coming in as a bleary eyed freshman and coming out as a doctor. Now you’re going on to the real world and it’s scary.”
Rubin touts Touro’s expertise in digital dentistry, enabling this move to virtual learning. The school uses the Canvas educational software package, and Rubin has even given exams online. However, the lack of hands-on learning does make him concerned about students’ and their skill sets. When students return to campus, classes will be much different.
“Our simulation lab had 109 students at a time. Now we’ll have to have them tested to make sure everyone is COVID-negative, and then we’ll have to practice social distancing and have our clinical parts in a staggered environment. We’ll have to break it up into clinical groups. I may have to teach my clinical class in a simulated lab in various groups,” he said, though he adds that he “wouldn’t be a good teacher” if he wasn’t considered about the reduced hands-on practical experience that will result from more online learning.
Meanwhile, working in his private practice and on campus has been a benefit in managing care during the pandemic and beyond, Rubin said.
“I get a tremendous amount of feedback and knowledge from a university-based environment to help me and my practice,” he said. “I gain the knowledge of experts in the field from the university, and I can take that knowledge to my practice. And at the university, my private practice is helping me become a better teacher.”
And now, Rubin and his colleagues will be able to treat all of their patients again. And providing routine care is the best way to ensure their oral and overall health, he said.
“Yes, we have to protect the people. But also we have to treat the people. And that’s a difficult balance to achieve right now,” he said. “This is people’s health that is at stake here.”
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