The coronavirus pandemic has created widespread challenges for the dental care delivery system in the United States. The Centers for Medicare & Medicaid Services and the American Dental Association issued recommendations in mid-March urging that all elective and nonemergency dental procedures be delayed. As states start to loosen their restrictions on dental offices, providers are making drastic changes to the way their practices function.
Minnesota is one of 12 states that have authorized dental therapy in some form. These midlevel providers can perform preventive and routine restorative services, including filling cavities and placing temporary crowns, allowing practices to expand their reach to typically underserved populations. In this Q&A, two advanced dental therapists discuss the pandemic’s impact on their ability to provide care.
Christy Jo Fogarty works for Minneapolis-based Children’s Dental Services (CDS), a nonprofit clinic that annually serves more than 37,000 children, young adults under 26, and pregnant women in two full-service offices and through portable dental services delivered in schools, Head Start centers, homeless care events, and other locations.
Heather Luebben is employed by Apple Tree Dental, a nonprofit organization that serves more than 34,000 patients annually at seven locations across Minnesota and through on-site care at 145 Head Start centers, schools, group homes, senior assisted living programs, and long-term care facilities.
These interviews, conducted in early May, have been edited for clarity and length.
Fogarty: CDS is seeing patients who need urgent care, and we are currently accepting patients of any age unable to see their regular dentist to ensure they stay out of emergency rooms. I am treating cavities using techniques that do not require a drill or hand piece that creates aerosols, such as by using silver diamine fluoride (SDF) and temporary medicated fillings. I also place temporary stainless steel crowns using a noninvasive technique and do extractions on primary teeth.
Luebben: Apple Tree is open for emergency care and treatment for patients with high-priority needs. I was furloughed for five weeks beginning March 17 but was brought back on April 20. I am seeing patients for emergency care and helping implement our teledentistry program. I am busy triaging and performing problem-focused exams, doing pediatric extractions and some adult extractions for badly diseased teeth, and treating tooth decay with SDF and temporary fillings.
Luebben: We video chat through Microsoft Teams, which allows us to comply with federal privacy rules. Teledentistry involves performing a limited oral evaluation. These can be performed by both dentists and advanced dental therapists in Minnesota.
Fogarty: We had been using teledentistry long before this crisis and continue to use it when applicable. In our practice, advanced dental therapists primarily perform tele-exams. We can screen for possible COVID-19 patients, prioritize patient care, and create preliminary treatment plans.
Fogarty: We are screening patients for signs and symptoms of flu or COVID-19 and taking temperatures before they enter the clinic. We try to minimize the use of hand pieces that create aerosols. Dentistry is a high-risk profession, and because of the limited access to personal protective equipment (PPE), we worry about exposure. But if I don’t provide the needed emergency care, a young child could be exposed to COVID in an emergency room.
Leubben: We are wearing N95 masks, face shields, and safety glasses. Our lab coats and disposable gowns are changed after each patient. We are being as safe as possible.
Fogarty: Yes, many patients come in wearing masks and are very aware of social distancing. We are staggering patients so only one family is in the waiting room at a time and only one parent is allowed with a patient. We also try to limit the amount of time that patients are in the waiting room. The dentist and I work at different ends of our large clinic.
Leubben: Most patients have not expressed worry as they are in so much pain that any risk is likely worth it to them at this point. That could change as routine care becomes more available, but we are well prepared to educate patients on how we are protecting them.
Leubben: Underserved populations who already face barriers to care are going to be left even further behind by this. I think this is going to take time to dig our way out.
Fogarty: We already had a waitlist to get patients in for dental surgery. In addition, many more minor cases could become much more complicated and require surgery. Those most at risk are on public assistance programs and make up about 90% of our patients. We also serve many patients experiencing homelessness. These people struggled to get care before and will face greater barriers because of the virus. Additionally, we cannot travel to the rural areas we normally serve, causing people to travel hours to receive care. Many dental offices may not survive financially. As a result, we could see fewer providers, especially for those most in need, because public programs reimburse at lower rates and dentists may need to maximize profit to continue to keep their practices afloat.
Fogarty: I suspect that until we have a vaccine, increased levels of PPE and social distancing will be recommended along with limits on scheduling times and the number of patients seen in a day. We will likely continue screening patients over the phone and using teledentistry for diagnosis and treatment planning.
Leubben: Teledentistry and minimally invasive dentistry are the wave of the future. SDF and other noninvasive techniques that do not require hand pieces should be used more readily instead of drilling when possible.
Luebben: There is an economic advantage to employing lower-cost advanced dental therapists to provide care for patients who have early and moderate stages of tooth decay. As we reopen for more procedures, we will continue to expand our teledentistry services, which reduces use of PPE, time, and number of patients in clinic, and helps triage those that require priority treatment.
Fogarty: Dental therapists are uniquely qualified to help underserved populations, and it will be even more critical to treat these patients post-COVID. Vulnerable populations face many barriers to accessing dental care, and one is often transportation. Dental therapists can work under general supervision, allowing us to go into schools, Head Start centers, and community health centers to provide services while decreasing or eliminating travel for patients.