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By Anne Blythe
Michael Riccobene had just completed an emergency root canal for a man whose front tooth was bothering him so much the patient could have ended up in an emergency room.
In the middle of the COVID-19 pandemic, patients have been reluctant to set foot in hospitals, and hospitals have tried to keep emergency rooms clear of unnecessary visits to try to better contain the virus.
Through most of April many dental offices in North Carolina were either fully closed or open only for such procedures as the one Riccobene had just done for the man visiting from Boston who called for help.
As the state eases some social distancing restrictions Riccobene and many other dentists across the state have mapped out plans to open for more routine cleanings and other oral health care, knowing full well that COVID-19 spread is a continued threat.
Riccobene Associates Family Dentistry has 36 offices across the state from Wilmington to Charlotte. During recent weeks, Riccobene, who is based in Cary, surveyed staff and got his offices ready so the practice could start seeing more patients.
“I think everyone is really nervous,” Riccobene said. “Employees are nervous. Patients are nervous.”
The North Carolina Dental Board of Examiners, the licensing agency for dentists and hygienists, held a board meeting recently to discuss best practice recommendations for opening offices after the existing statewide stay-at-home order is modified.
“The purpose of this statement is to provide resources to help guide dentists in the safest possible way to offer dental services, including safely and deliberately offering emergency, non-emergency, and routine services, and to do so in such a way as to reduce the risk of COVID-19 transmission to patients and Dental Health Care Personnel (DHCP),” the board said in a statement posted to its site. “Although individual dentists may use their professional judgment as to what procedures to perform and when to perform them, failure to follow heightened infection control, sterilization, and patient safety recommendations may be viewed as a failure to meet the standard of care necessary for offering treatment during the COVID-19 pandemic.”
Riccobene said that statement has been helpful for dentists and hygienists who struggled for more clarity earlier in the pandemic.
Many reached out to the board in mid March asking for the closure of all offices. The board issued a statement then, saying it lacked authority to close businesses. The governor has that power, the board argued at the time.
Though dental practices were not ordered to be closed, the board issued guidance on March 16 for offices to limit their procedures during the State of Emergency to emergency procedures only.
“The reality is, we could have said buzz off,” Riccobene said. “What we did in the meantime, we were closing offices and donating a lot of personal protective equipment.”
Before COVID-19 changed the world, Riccobene had more than 600 workers. Over the past month, he has laid off or furloughed 450 employees. His recent survey of workers showed that 60 employees are not willing to come back at this moment.
Dentists and the hygienists who work alongside them have been described as workers in the very high exposure risk category for COVID-19 by the Centers for Disease Control and Prevention.
Riccobene says he understands that some people in his offices might be worried about returning to work while there is no COVID-19 vaccine.
Some of those who expressed such sentiments have underlying conditions that put them at an even higher risk for serious complications from virus infection. Others live with an elderly parent or someone more vulnerable to dire circumstances.
“I’m not going to hold it against them,” Riccobene said.
Guidelines without regulations
Heather Perry, a hygienist at an East Carolina University oral health clinic, said this week that she is ready to get back to work.
“I’m not personally afraid to go back,” Perry said.
But she knows from following Facebook pages where dentists and hygienists frequently post that there are many hygienists nervous about what’s ahead.
Some who work in smaller offices worry that there will not be enough personal protective equipment to shield them as thoroughly as they would like. Part of the problem, Perry added, is that the American Dental Association and the state dental board are issuing guidance not supported by regulation.
Some are ready to get back to work as Perry is. Others, though, are more anxious about complications from a virus that still has so many unknowns.
“We’ve dealt with blood pathogens, but we’ve never dealt with anything like this,” Perry said.
The North Carolina Dental Hygienists’ Association acknowledged concerns in a letter posted to its site on May 1 from the organization’s president, Heather Edly, and other officers. They encouraged hygienists to have frank discussions with their employers.
NC Dental Hygienists Assoc. Statement (PDF)
“The wording of the Dental Board’s statement was specific and targeted regarding the OSHA, ADA, and CDC guidelines for patient care/safety and employee health protections are to be followed as referenced,” the letter states. “It is not business as usual, it is the new way of practicing dentistry. NCDHA supports the board’s statement ‘failure to follow heightened infection control, sterilization, and patient safety recommendations may be viewed as a failure to meet the standard of care necessary for offering treatment during the COVID-19 pandemic.’ We understand your concerns and hear all the questions being asked. Ensuring your safety as a hygienist and the environment in which you will be working is the safest and healthiest place for you to be is our utmost priority.”
Stocking up on PPE
Riccobene said his offices will look different. Half the seats in the waiting rooms will be taken out. Any patients uncomfortable sitting there will have the option of waiting in their cars until the hygienist or dentist is ready for them.
The air will be scrubbed through high-efficiency particulate air filters, he said.
After contributing much of the personal protective equipment that had been in his officers before the pandemic to frontline workers during the supply shortage, Riccobene has been stocking back up so employees in his offices have masks, gloves, gowns and more.
Though he has not had trouble getting the N95 masks, which remain in short supply in the state and across the country, Riccobene said the price for them has increased exponentially.
Before the pandemic, he could get an N95 at about 90 cents per mask. Through his supply contact, Riccobene said he has been able to get them for about $3 to $5 per mask, but knows some suppliers are asking $7 per mask.
That increase has Riccobene and other dentists contemplating a PPE fee. They’ve been lobbying insurance companies to allow them to add that to the cost of a visit.
Riccobene, who has been practicing dentistry in North Carolina for 24 years, noted that dentists have been wearing goggles, masks and other protective equipment for years.
The HIV/AIDS pandemic changed dentistry, he said, compelling workers to use more gloves, goggles and other barriers to prevent transmission of bodily fluids. Other diseases such as tuberculosis and SARS can be transmitted through airborne aerosols.
There is a contamination risk, but most dental practices do their best to keep them as low as possible.
The Occupational Safety and Health Administration, or OSHA, has issued guidelines for dentistry workers and employers that include tasks and exposure risk levels.
Face shields or goggles are recommended for workers.
Riccobene plans to screen patients before they come to the office, asking about coughs, fever, recent travel patterns and potential contact with people who’ve contracted COVID-19.
Workers will be screened for fever, too, through routine temperature checks.
“As dentists, we’ve been dealing with airborne and bloodborne issues for a while,” Riccobene said. “The only 100 percent guarantee you have is to not see patients at all.”