Iowa dentists were anxious. In early March, the coronavirus pandemic was swelling and nobody knew what to do. Should they see emergency dental patients only or shut down their practices completely? Could everyday use of aerosol sprays in dental procedures increase the spread of virus-containing droplets from the mouths of infected patients? Dr. Ryan Stuntz, 41, was at helm of the Iowa Dental Association as COVID-19 approached.
“Other states were closing, so we had an emergency board meeting and we discussed what to do,” Stuntz says. “When the protective personal equipment supply was very uncertain, it didn’t make a lot of sense for us to keep using all those pieces of PPE in our practices. There was a good chance, we all felt, that in a couple of weeks hospitals could be overrun. As a group, we decided that we should switch over to seeing emergency patients only. Now, obviously, that doesn’t have the force of law, but most practices shut down then.”
On March 26, Iowa Governor Kim Reynolds made it official by closing dental offices except for emergency procedures, in line with what was happening around the nation. Stuntz (whose term as IDA president ended in May) provided leadership and reassurance during this period of uncertainty. He served on an Iowa task force to develop the plan for reopening dental practices in the state, a collaborative effort with input from groups like the Iowa Dental Hygienists’ Association. And he made sure dentists had accurate information throughout the process.
Holding mega-Zoom meetings for hundreds of dentists was a new — and rewarding — career experience for Stuntz. Experts from the Iowa Dental Board, Iowa Department of Public Health, University of Iowa College of Dentistry and American Dental Association gave presentations and fielded tough questions from dentists during the events.
The point was for members to get answers straight from the sources rather than secondhand misinformation. “It really helped keep rumors from spreading,” Stuntz says. “It kept it from being a more anxious situation than it needed to be.”
Dental Patient Safety
The Centers for Disease Control and Prevention currently recommends that dentists use additional infection prevention and control practices for all patients during the COVID-19 pandemic. How concerned should dental patients be about their safety from the coronavirus?
Stuntz and his wife, Dr. Melanie Stuntz, also a dentist, run the Farley Dental Center, a private dental practice in Farley, Iowa. “With the protocols we have in place, I think you’re safer at the dental office than you would be in the grocery store,” he says. That’s not a knock on supermarkets, he adds — it’s just that dental offices are staffed with professionals who have infection control ingrained among them from their earliest training and cemented through daily practice.
“We have new protocols in how we would clean the office, new protocols in our PPE,” Stuntz says. Previously, for instance, dentists would typically change masks and gloves and wash their hands after each patient. “But after the pandemic, then we’re wearing N95s and another mask over the top.” Face shields also became the norm. In addition, some team members choose to wear hairnets and shoe coverings.
“It’s really a change to have to don and doff everything between patients,” Stuntz says. Most dental practices are small business, so simply finding space to accommodate frequent garbing and regarbing can be an issue.
Aerosols are considered a potential hazard for coronavirus transmission, and certain dental procedures using high-speed handpieces, lasers, air polishers, electrosurgery units and other instruments may result in aerosolization. Aerosols have the potential to make infected droplets go airborne and reach nearby people and surfaces. Therefore, minimizing aerosol generation is now a priority for Stuntz and colleagues.
Dentists, when performing aerosol-generating treatments, usually have a dental assistant working alongside them using high-vacuum suction to catch more aerosols, he explains. Before the pandemic, dental calculus — the hardened plaque that can’t be removed by brushing, also called tartar — was sometimes removed by hygienists using ultrasonic scaling, rather than the previously standard tool to scrape plaque and tartar away by hand. These vibrating instruments work by spraying water into the patient’s mouth. “It’s a lot nicer for the patient and a lot nicer for the hygienist,” Stuntz says. “It saves their wrists and their careers, hopefully.”
But with pandemic restrictions, hygienist have had to return to hand-scraping unless they have access to an N95 mask, to avoid contact with aerosols. To improve safety, Stuntz’s dental center placed new suction units in each hygienist’s work space. The units pull aerosols out of the air, run them through a medical-grade filter and kill any viruses or other organisms that could get back into the room. The device helps reduce the risk of exposure for staff and the next patient by lowering the amount of aerosols circulating in the treatment area.
Most offices have taken additional measures, Stuntz says, such as adding filters to air conditioners and putting in aerosol-catching devices or foggers that create a mist of hydrogen peroxide that drags aerosols down to the floor, thus greatly reducing the likelihood of infection through lingering aerosols in the air. “There are a lot of tricks to reduce that aerosol, and from what I’ve seen people do, they’re taking it very seriously.” In addition, some offices have put barriers between all the rooms, or started using ultraviolet disinfection between patients.
In mid-May, Iowa dental offices were permitted to go back to seeing nonemergency patients. By then, Iowa dental practices had implemented new safety measures and were ready to gradually welcome back patients.
“Most offices phased it in over a few weeks,” Stuntz notes. “They didn’t just roll the doors open and have a wide-open schedule.” Starting out gradually allowed practices to see how spacing patients out was working. “You work your way back up to see more patients, to make sure you’re doing it well and you’re following all the protocols.”
Dental visits look different now. Waiting rooms, no longer crowded, are stripped bare of frills. “Most offices took all their magazines out; they took their toys out — things that people are touching,” Stuntz says. “We created space of at least 6 feet between people in the waiting room.”
Patient flow has changed. Appointments are staggered so patients don’t arrive at the same time. Once patients enter the office, they only wait a few minutes before being taken back to the dental chair. “Everybody in the building has to wear masks — no exceptions,” he says. “Temperatures are taken.”
Within a couple weeks of reopening, everyone became more comfortable, Stuntz says. The realization was: “You’re able to see more patients, and still clean the rooms, disinfect and make sure everything is sterilized and sanitary for the patients.” At this point, he estimates that his practice numbers are about 85% back to normal.
“As a patient, there’s nothing wrong with asking questions of the dental office,” Stuntz says. “You could ask: What are their protocols? Are they requiring masks? Are they requiring screenings? Have they made any engineering control changes to where they’re reducing aerosols in the operatories?”
To date, no large COVID-19 outbreaks have been traced back to a dental office. A few small case clusters have occurred, including at two dental practices in Colorado Springs that reported positive tests in some staff members.
Importance of Dental Care
Iowa has been affected by the pandemic similarly to the rest of country, Stuntz says. “We are seeing a rise in cases right now,” which he notes may be driven by younger, college-age people infected with COVID-19. “The colleges have opened up and all those counties have seen about 25% positivity rates.” The largest daily spike in Iowa cases to date occurred on Aug. 18, with more than 2,600 new cases.
The pandemic has made it almost impossible to hold large-scale charitable events. “We usually have events like Mission of Mercy, where people are given free dental treatment,” he says. “We use a convention center or an arena, but given the concerns about COVID transmission, almost all of these events across the country have been canceled.” Many dentists are eager to resume events for patients in need who might otherwise fall through the cracks and suffer from treatment delays.
Stuntz encourages everyone to keep up with their dental care. “If you were to contract COVID, you don’t want to be the only one with a dental abscess and COVID at the same time,” he says. “You want to be a healthy as you can, so that if you were to contract it, you have the highest chance for success and having a good outcome.”
As a patient, you can help by making sure you’re healthy before a routine visit, Stuntz says. “If you have symptoms (of COVID-19), let the office know,” and you’ll still be treated for urgent dental issues, he adds. “It may be a different protocol, but if you have swelling they’re going to find a way to treat you. They’re not going to let you flounder.”
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Iowa Dentist Practices Leadership During COVID-19 Pandemic originally appeared on usnews.com