Tennessee Practices Reopen While Massachusetts Waits

14 May 2020
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The Centers for Disease Control and Prevention (CDC) continues to recommend that dental practices postpone elective procedures, surgeries, and non-urgent dental visits, though the CDC says an update is underway. Despite this federal guidance, available dental care varies across the country.

Tennessee allowed its dental practices to reopen to elective care on May 6. Massachusetts, though, is operating according to the Massachusetts Dental Society (MDS) recommendation to keep dental offices closed to patients seeking elective and non-urgent care through May 18. However, dentists in the state should remain available for emergency treatment.


Tennessee

The Volunteer State was among the first to allow its dentists to resume non-emergency dental and oral procedures including hygiene and other elective treatment. Of course, dentists such as former Tennessee Dental Association (TDA) president Rick Guthrie, DDS, of Bristol continued to provide emergency and urgent care during the shutdown.

“Basically it was abscesses, infections, broken teeth, and stuff that would keep folks out of the ER,” said Guthrie, whose father and son both also are dentists at the family’s practice. “Basically my son covered two days and I covered two days. It was surprising. Sometimes we saw just two or three patients. There was one day I think we saw seven. We just had a lot of problems.”

The practice had to reduce its staff from 16 employees to four, who rotated so there would always be one doctor, one assistant, and one member of the front office on site. They also reduced the waiting room from 24 seats to 10 with a maximum of four people waiting at any one time. The new workflow required a lot of preparation.

“We spent hours coming up with these changes. Basically we’re doing prescreening before you ever get here,” Guthrie said. “We’re actually recommending that people not come until their appointment time. When we’re ready to do so. When they walk in the door, we’ve already prescreened them. We ask them a few questions. We do their temperature. And then we’re ready to put them in the treatment room.”

Infection control in the operatory is a priority as well, though Guthrie says his practice already had extensive protocols in place before the pandemic. His staff will continue to follow them as they begin seeing non-emergency patients. In fact, hygiene and other elective procedures are already underway, with a waiting list of people who want to get their teeth cleaned.

“I am encouraged. I was afraid people would be afraid to come to the dentist. But I think they trust us and they feel like they’re safe here. We make sure to tell them we appreciate them, and we tell them if they do not feel comfortable or do not feel safe, please don’t come. But we’re here,” said Guthrie.

Guthrie also said that as new standards emerge, his staff is ready and flexible enough to accommodate them. As a former TDA president, he was “at arm’s distance” as the state developed its guidelines, and he praises current president Dr. Terryl Propper and the TDA’s current efforts in working with the state government to develop those guidelines.

“I was in contact with the current president. She was really on top of things,” he said. “The Tennessee Dental Association did a good job coordinating with the governor and the Department of Public Health, so I’m grateful for what the Tennessee Dental Association did.”

Dentistry’s own history gives him confidence in navigating the crisis as well.

“We were at the forefront when AIDS happened 30 years ago. We really put a lot of infection control measures in place then. We’ve built our standards. We’ve been a pretty safe place to come to for a long time,” he said.

“Unfortunately, COVID-19 is going to be around for a little while. And that’s what I tell my staff. We’re going to do everything we can to be as safe as possible. We’re going to have to learn to work around COVID-19 and do things as safe as possible because I don’t see any end to it in the near future,” he said.

Massachusetts

MDS president Janice Moriarty, DMD, also has been seeing emergency and urgent patients, noting that her practice in Winchester “never really closed.” Cases have included broken teeth and referrals to oral surgeons for extractions. She expects to reopen to non-emergency patients on May 18, and her office has been contacting patients to reschedule appointments.

“We do hope we can expand our scope of treatment in the near future based on patient and staff safety, number one, and we certainly realize it’s not going to be going back to business as usual,” she said. “It needs to be a slow phase-back or ramp-up to require social distancing, as much as you can do that in dentistry. When we say that everyone laughs, because obviously a dentist cannot provide dental treatment to a patient from six feet away.”

Patients are triaged by phone and seen in the office as needed. Moriarty also touts her practice’s surgically clean air filtration system and adherence to OSHA guidelines. She and her staff are using enhanced PPE as well including N95 or KN95 masks, disposable gowns, hair covers, shoe covers, and more, though supplies have been difficult.

“PPE supply is a challenge for dentists across the nation, as far as I know,” she said. “We’ve been told by the American Dental Association that FEMA was controlling the supply chain, and obviously the most critical need in the beginning was to get it to the medical frontlines. We hope that opens up quickly with the Defense Production Act because it is the number one need.”

Yet PPE supplies remain the responsibility of the practice’s owner and dentist, who must make the ultimate decision if they are ready to reopen, she said.

“I have heard many dentists stating weeks ago that they just feel that it’s better to pick a date further out. I hear June 1 a lot from my friends, so it’s always up to the professional judgment of the dentist. Now that works great if you’re a dentist that owns a practice. If you’re a dentist that’s an employee of someone else, there’s a different story there,” she said.

As president of the MDS, Moriarty has been working with the state’s Department of Health on its guidelines for reopening. She says that the department and the governor both have been in alignment with the MDS’s recommendations without many discrepancies.

“Never did I think as a dentist would I be forced to close my office to all but emergency patients, but our Board of Trustees at the dental society had to make that decision,” she said. “We based our recommendation on facts at the time in terms of flattening the curve and trying to look at the science as best we could.”

When Moriarty does resume her full scope of practice, she expects the PPE requirements and limitations on the number of people in the office to remain. Her staff also will continue to ask screening questions about potential COVID-19 exposure and symptoms, take temperatures, give patients masks to wear, and have them wash their hands and use hand sanitizer. These requirements will have a significant impact on scheduling.

“So the first three months, we’re just thinking we’ll be working at 25% to maybe 40% capacity. Hopefully in six months we can ramp that up to a higher capacity, and possibly it might not be a year until we can see things on a more ‘old normal’ basis,” she said. “And a lot of that is going to have to do with testing and the eventual discovery of a vaccine.”

Staffing will be impacted too. The practice will hold off on hygiene appointments for now. Training, especially in new PPE donning and doffing protocols, will be part of the routine. Moriarty also will split and schedule her staff into two teams that will have no overlap. That way if someone on one team is infected with the virus and the whole team needs to be quarantined, the other team can keep working and keep the practice open.

“It’s understandable that the staff is anxious about it. But I’ve found so far when they hear how thought-out the approach and the plan would be, and why we’re recommending everything we’re recommending, they do feel a bit better because they understand we’re doing our best to keep their risk as low as possible,” she said. “Risk is never zero. We know that. The virus is out there. But we want to keep it as safe a workplace and a treatment place as we can.”

Looking Ahead

Despite the changes in dentistry overall and the differences between their respective practices, Guthrie and Moriarty remain optimistic about reopening and the future.

“I feel pretty comfortable with starting back to work like we’re doing,” Guthrie said. “We haven’t shortcut anywhere that I can see. There may be standards coming out, and we’ll be ready to change.”

“It’s been tough times for sure for everybody,” Moriarty said. “As a practice owner, it was very difficult to have to furlough staff. But that was the best option at the time. Now we hope to slowly return to treating more patients and doing more procedures as long as it takes to do so.”

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