Dr. Norberto Camacho says he’s drenched in sweat and yearning for oxygen after every shift at his dental practice in Brickell, where the AC is stuck above 72 degrees and staff are adapting to multiple new layers of personal protective equipment.
With an 80-year-old grandmother waiting at home and Florida hitting more than 244,000 confirmed COVID-19 cases and more than 4,100 deaths as of Friday, Camacho, 35, is determined to minimize the risk of infection for his team and his patients.
So at his practice, Dental World Miami, he wears two face masks — an N95 covered by a thinner surgical mask — a face shield and helmet, and heavy magnifying protective glasses that weigh down on his nose bridge leaving dark red marks.
“It’s a nightmare. It’s hard to breathe… Most days, I feel like I want to go home and cry,” Camacho said.
“But is it going to make my patients feel safer? And is it gonna make us — the staff — be safer? Yeah. Then I’m going to do it.”
After almost two months of emergency-only care, reduced patient volume and pay cuts, most dental practices in South Florida have reopened with extensive new screening and disinfection protocols that include questioning staff and patients regularly about COVID-19 symptoms, moving waiting rooms to spacious parking lots and investing in technology.
“Unless you are in a very high-risk group... it is definitely safe to go to the dentist,” said Dr. Rudy Liddell, the immediate former president of the Florida Dental Association and the upcoming Florida trustee to the American Dental Association.
But many patients are hesitant to come back, and some staff members are refusing.
In mid June, more than 60 percent of dental practices in Florida reported seeing fewer patients than usual. And while some dentists like Camacho said they are reducing contact by choice, many others are eager to restore normal patient volumes to make up for significant COVID-related financial losses in April and May.
Dentists are stressing that the Centers for Disease Control and Prevention has not reported any documented cases of COVID transmission in dental settings and reminding their patients that untreated dental conditions can cause health issues.
However, a group of dental hygienists is cautioning patients that there is still no evidence that the benefits of dental treatment outweigh the risks.
“Offices are moving ahead full-steam... but they are giving the public a false sense of security,” said Sara Ziegler, the administrator of Hygiethics, a national Facebook group of more than 1,800 dental hygienists, of which 1,200 quit or were laid off from their jobs for, they say, questioning safety standards in dental practices.
Ziegler said 500 to 600 of the group’s members practiced dentistry in Florida.
Some also suggest that dental practices are failing to report COVID-positive cases among staff to avoid another month-long shutdown due to mandatory quarantines.
New industry standards for dental practices
In Camacho’s practice, only two practitioners and two patients are allowed in the space at the same time, with the hygienist on one side of the office while Camacho is in an enclosed suite on the opposite side.
While the CDC recommends a distance of 6 feet between people, Camacho set a 10-foot standard in his office, which staff enforce at all times except when treating patients.
Every patient is required to fill out and sign a questionnaire to screen for COVID symptoms.
Staff then take patients’ temperatures at the door with infrared thermometers that do not require physical contact and ask them to rinse their mouths with a hydrogen-peroxide-based solution, a pale blue liquid that has shown promise as a decontamination agent against COVID, according to the CDC.
These are some of the precautions the ADA’s Advisory Task Force for Dental Practice Recovery, a group of practicing dentists and ADA experts in science, law and regulation, recently recommended to all dental practices in the nation.
Liddell, the co-chair of the task force, said dental professionals were already at a significant advantage to confront the pandemic.
When Liddell began working in dentistry in 1986, he said dentists didn’t wear eye protection, masks and gloves. But the HIV scare of the ‘80s turned personal protective equipment into an industry standard.
Now the task force is building on these preexisting measures to address the threats of the coronavirus pandemic, Liddell said.
New recommendations include substituting “surgical masks, which do not seal around the nose and mouth, (and) are not adequate to completely protect against aerosol-borne disease transmission,” according to an interim guidance summary of the task force’s findings released on June 24.
Liddell and his team recommended instead that practices stock up on N95 masks or their near equivalent, KN95s.
The task force also suggested screening patients with questionnaires and temperature checks and avoiding open-mouth treatment when possible.
“We mitigate the risk of aerosols — small particles of saliva, tooth debris and dental plaque, which could potentially spread the virus from patient to staff — by (making) the patient wear a rubber dam,” which isolates teeth while covering the mouth, said Dr. Mark Limosani, a dental specialist that focuses on diagnosing and treating tooth pain in Weston.
But Limosani said that while in his specialty, endodontics, rubber dams can be used often, other dentists don’t have that luxury.
Dr. Raul Gonzales at Smile Studio in Doral minimizes the risk of infection by requiring staff and patients to bring a clean change of clothes and shoes to change into every time they enter the office.
Other dentists like Camacho are using new technology to keep their offices safe.
Camacho said he screens patients with an SpO2 monitor, a device that pierces the fingertip for a drop of blood to measure blood oxygenation, which is believed to help detect symptoms associated with COVID such as shortness of breath.
Camacho also equipped his office with hospital-standard ventilation technology, while other dental practices are using disinfectant foggers, machines that blow a disinfectant solution across an office to kill bacteria.
Liddell said there is anecdotal evidence that these technologies can be helpful, although in his five-doctor practice in Brandon, on Florida’s west coast, he and his colleagues have chosen to wait for scientific evidence to confirm that the devices are worth the expenditure.
But Liddell warned against other technologies such as indoor UV light sanitizers — electric blue panels used in some dental offices that emit radiation — which he said could cause damage to the skin of staff and patients.
A post shared by Dr Mark Anthony Limosani (@westonendocare) on Mar 28, 2020 at 3:11pm PDT
Dentists encourage patients to resume regular appointments
Although the task force said dentists should avoid seeing patients face to face as much as possible, opting instead for teledentistry for non-emergency cases, most dental offices are encouraging patients to come in for regular appointments.
After Gov. Ron DeSantis issued an executive order prohibiting all non-emergency medical procedures on March 20, four out of five dental practices in Florida reported collecting less than 10 percent of their usual profits and nearly 20 percent of practices suspended pay for all staff members, according to poll data collected by the ADA.
DeSantis lifted the order on May 8. And while practices began to bounce back in June, more than 30 percent of dental offices in Florida still reported making half or less of their usual profit, the data shows.
Camacho said the crisis forced him to let go of one practitioner in training. His staff also experienced pay cuts of up to 60 percent, leading many in his office to file for unemployment.
At Smile Studio, most of the staff was out of work for nearly two months.
“It was hard. I was a little bit scared at the beginning, but not anymore,” said Marianna Vargas, 24, who’s been working as a receptionist at the practice for two years. After a 50-day period of uncertainty, Vargas said most of staff have returned to work full time.
For Dr. Beatriz Terry from Miami Implant Perio, a dental implants periodontist in South Miami, the emergency-patients-only restriction meant working one day per week and suspending pay for most of her staff for two months.
Although Terry was able to rehire the great majority of her team in early May, she said the pandemic had a significant financial impact on her personally, her practice and her staff, with many having to file for unemployment benefits.
“Some people voluntarily chose to stay home and I wasn’t going to insist on anyone coming in that didn’t feel comfortable coming in,” she said.
Now, Terry is determined to restore and maintain patient volume to normal levels.
Terry also warned that neglecting dental hygiene and delaying treatment can be harmful to patients’ health, in some cases even leading to heart disease, diabetes or cancer.
She said that COVID-related stress may also be driving an uptick in cracked teeth, a pattern which many of her colleagues in South Florida have been noticing since April.
Personal protective equipment is still hard to find
Some offices in South Florida are intentionally keeping patient volume low due to the statewide shortage of personal protective equipment, or PPE, which is mostly diverted to medical professionals on the front lines.
“We only brought in (as many) people as our PPE allowed,” said Dr. Patrick S. Lolo, a pediatric dentist at Nicklaus Children’s Hospital.
Although the number of dental patients at the hospital rose significantly during the lockdown as many private clinics shut down, Lolo said his team had to turn down dozens and have many others wait for hours in the hospital’s parking lot due to PPE limitations.
In early May, more than 30 percent of U.S. practices said they were out of N95 masks and an additional 30 percent said they had seven days or less worth of stock, the ADA’s data shows.
Addressing the shortage became a priority of the task force, which distributed about 1.5 million KN95 masks free of charge to dental practices nationwide as of early June.
But in the week of June 15, about 8 percent of dental practices in Florida still said they had no N95 supplies, while almost 23 percent said they had a week or less worth of supplies, according to ADA data. Similar percentages were reported for disposable gowns.
The South Florida Dental Hygienists Association reported Friday that dental offices were also struggling to cover the rising costs of supplies.
“Some offices are sterilizing gowns and masks to be able to reuse (them) since it’s difficult to get a steady supply,” said the SFDHA President Dr. Ileana Pino, referencing a practice which the CDC warns could increase the chances of exposure to the virus.
Camacho said he was fortunate to stock up on masks and shields early, approaching the pandemic as he would a hurricane.
“When there’s a hurricane, you know that you need to get your stuff because, a few days later, there’s not going to be anything in the aisles,” he said. “It was inevitable that with COVID it would be the same.”
However, Camacho’s N95 stock is not sufficient to dispose of N95s after every visit, the gold standard recommended by the ADA. Instead, Camacho and his staff cover their more valuable masks with less protective surgical masks and dispose of those instead.
Lolo said he also overlays surgical masks to preserve N95s, while Terry said she mandates that all staff wear surgical masks, protective shields and eyewear, but she reserves her limited stock of N95s for potentially COVID-positive patients.
So far, Terry said none of her patients have reported testing positive for the virus.
“As far as reusing masks, I reuse my own mask until it gets soiled or the straps break because quite honestly it’s very difficult to get an abundance of supply of the appropriate ones,” said Liddell.
‘It’s not worth the risk’
In some practices, the supply shortage, together with growing concerns about the enforcement of safety standards in dental settings, drove staff members away.
“Some of them (hygienists) have decided not to go back,” said Pino, who represents hygienists in Broward, Miami-Dade, Collier and Monroe counties. “Others, I hear, have been fired because they were questioning protocols that the office set in place.”
Pino said many hygienists — who are among the most at-risk staff members in dental offices because they work directly over patients’ mouths — reported being uncomfortable reusing masks multiple days per week and rushing to disinfect office rooms in 15 minutes or less.
Hygienists are also experiencing higher-than-usual stress and physical fatigue, as they are being asked to perform all cleanings without electric tools that produce higher levels of aerosols, according to Pino.
“It’s not worth the risk,” Pino said some members told her.
Two to three hundred hygienists just in South Florida left their jobs because they either felt unsafe or worried that they were putting their patients at risk, according to Kayte Bush, a dental hygienist in Pinellas County, who tried to put together a union of dental hygienists and assistants in the state and reportedly abandoned the project after receiving threats.
Bush said she was one of many to get fired for speaking up.
The group is calling on the CDC to conduct dentistry-specific testing to ensure that their work environments are safe and that the public can make informed decisions about their healthcare.
Meanwhile, most dentists said they trust screening questionnaires and the good will of their patients.
“No one likes to go to the dentist. I’m not a spa or a restaurant, although we try to make visits pleasant,” said Camacho. “So I would hope for goodness sake that if someone’s going to the dentist, they would tell us if they feel bad or if they’ve had any symptoms.”