One is reminded of the opening lines of Charles Dickens’ A Tale of Two Cities: “It was the best of times, it was the worst of times.” Depending on the demographic served, these are either times of prosperity or austerity in the dental industry.
During the pandemic, savings rates in the United States reached historical highs. Populations that remained employed or had substantial retirement income continued to prosper. Trading markets that initially sustained significant downward pressures today have rebounded to nearly former highs.
Options to spend disposable income have diminished, including sporting events, travel, theater, dining, and shopping. Concurrently, certain industries have been devastated such as the airline industry, restaurants, cruise lines, entertainment, non-critical hospital services, many retail businesses, and the lodging industry.
As some businesses are crushed and their employees laid off or terminated, other people are strengthening their personal wealth. A significant element of the population has seen a substantial rise in their assets and disposable income. All the while, others are facing extreme hardship.
Another impact has been the requirement for many to work from home. This is particularly true in high-tech industries, which have commensurate well-paying jobs and benefits. Meetings conducted virtually utilizing modalities like Zoom and Skype are now the norm. Many of these skilled workers are leaving high-cost urban centers like San Francisco and New York City for the lower costs and greater quality of life in rural and small-town communities.
Style of Practice
For those dental practices that schedule one patient per appointment slot and pride themselves on seeing clients on time, the transition during the COVID crisis has not been excessively stressful. Yes, infection control measures inclusive of personal protective equipment (PPE) have been stepped up. Reception areas and countertops have been cleared. A few more questions have been added to patients’ health histories, not to mention body temperature scans.
By contrast, those practices targeting a challenged demographic often relied upon double and triple booking appointment times. Due to social distancing requirements, reception areas no longer accommodate high volumes of patients and families, as a lack of childcare often brought throngs into waiting rooms. Clinical treatment areas can’t be turned over as quickly now that there are increased infection control protocols.
Compounding difficulties in service to populations with lower incomes such as Medicaid or low-end PPO patients, fee schedules are locked into minimal remuneration per patient service. States are under budgetary pressure to decrease Medicaid payouts even further. Patients receiving care under discounted insurance plans are seeing employers drop this benefit or assume plans with even steeper discounts.
Many pediatric specialty practices only can economically assume Medicaid patients through the income gained by larger and more involved hospital cases delivered under general anesthesia. As hospitals are forced to limit services for outpatient sedation due to the pandemic, this revenue stream for pediatric dentists has frequently dried up.
Patient Stress and Dental Needs
The COVID-19 crisis has created a great deal of stress in our population. Schools revamping to virtual education have generated anxiety for students and parents alike. Uncertainties in the general workplace are common. Formerly routine events like shopping, going to church, and gathering with friends and family have assumed added trials. Incidences of depression, drug and alcohol abuse, domestic violence, workplace violence, and suicide are increasing.
The Bible cites 13 different examples of the “gnashing of teeth.” Parafunctional insult and damage to a stressed-out person’s teeth goes back into the days of antiquity. We know severe bruxing and clenching generates cuspal fractures, cracked tooth syndrome with associated insult and injury to the dental pulp, and temporomandibular disorders. The general public has been well alerted to this phenomenon during the coronavirus pandemic by the mainstream media.
Damage generated by severe clenching and bruxing of teeth has elevated need for treatment. This has already been recognized on a national scale by the ADA’s Health Policy Institute. Incidences of tooth grinding and dental fractures are up by more than 50% during the pandemic.
State mandated closures of dental practices for prolonged periods for all but emergency care have allowed relatively minor dental pathologies to worsen and mature. Small lesions of dental caries have grown larger, often exacerbated by patients’ deleterious diet and diminished homecare.
What once might have been resolved with routine fillings today requires crowns, root canal therapy, extractions, and dental implants. A lack of dental prophylaxis and periodontal recare visits has resulted in additional periodontal damage. A critical backlog of dental need has developed for many patients.
Winners and Losers
Very quickly into practice within the private sector, doctors recognize that dental need does not always equate to demand for dental services. Without adequate funding, those services either are not delivered or they may be delivered but in a seriously compromised manner.
The COVID-19 crisis has resulted in many practices losing their patient base, as patients become unemployed or underemployed or relocate. The business and practice management models for high-volume low-cost services are often no longer sustainable. This also includes the public sector.
Naturally, some practices ignore Centers for Disease Control and Prevention and state healthcare guidelines to remain economically viable. Many are under pressures from corporate dental chain directors to meet production targets and quotas regardless of public health safety.
By contrast, dental practices in other demographics are experiencing an influx of relocating educated patients of significant financial means, both employed and retired. These practices are benefiting from the additional disposable income of their patient population.
These educated patients expect and demand dental care in accord with social distancing and public healthcare guidelines. Moreover, they have a pent-up need for dental therapies and the personal finances to fund service for that demand.
Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at mwdavisdds@comcast.net or smilesofsantafe.com.
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