Surreal. Unfathomable. Unreal.

The first case of the novel coronavirus in the United States was confirmed in Washington state on Feb. 29, but it really wasn’t until the second two weeks of March when the magnitude of the outbreak began to become obvious, and everyday life changed — for everyone — for the foreseeable future.

The depth of this change was deep and profound, cutting across every community: School was cancelled for the state’s one million K-12 students. The mere act of grocery shopping was seemingly fraught with peril. Restaurants were ordered closed. In-person church services, weddings and funerals — not allowed. Favorite hobbies, youth sports and going to the gym were restricted or cancelled. Summer concerts, baseball — even the Olympics — all postponed.

Virtually every aspect of our daily lives was suspended — including the essential act of practicing dentistry.

“We’ve been tackling infectious diseases for years in dentistry,” said WSDA President Dr. Denny Bradshaw, who practices in Pasco. “At first it was frustrating because no one could make up their minds — this was a brand-new virus. No one had ever dealt with anything like this before. There were so many unknowns and I am a planning person. It was really, really unsettling for me personally,” he said.

“Being president of WSDA was a real gift because it got me off of thinking about myself and shifted to thinking about fellow dentists in the state of Washington — a place to focus my attention. It was incredibly time-consuming — all of the unknowns in my one office times 4,400 for the association, plus the well-being of the association itself,” he added.

“There were days I had to charge my cell phone multiple times — on calls with the association, sections of the board met six days a week at first then switched to four days a week. But for me it helped my sanity.”

In the eight months since the word “COVID” (along with “Zoom,” “masking” and “social distance”) first entered our lexicon, dentists have been working to slowly return their practices to what’s now considered the new normal and get a better handle on what the future holds for the profession.

In August, WSDA reached out to members to get their feedback on the pandemic — to learn what they might have done differently (in hindsight), how they might change going forward, and what hopes they have for the future. Responses varied in length, topic and tenor; some opted to remain anonymous.

Some, like Dr. Elisabeth Warder of Spokane, were hopeful in spite of things.

“I hope that we can get better technology. It is really hard to practice dentistry right now, in particular with face shields and N95 masks,” she wrote. “It is hard to breathe and hard to see. We need to find a safe way to reduce aerosols and be comfortable practicing dentistry at the same time.”

Others who responded were more direct: “I hate coronavirus.”

A CRISIS UNLIKE ANY OTHER

In many ways, COVID-19 represents the most perfect of perfect storms. It is a crisis of every proportion — at least six crises in one:

• A public health crisis
• A business crisis
• An economic crisis
• An information crisis
• A crisis of government effectiveness
• A social crisis

It is unlike previous pandemics, natural disasters or corporate crises. And the situation, even today, changes constantly.

The pandemic brought many industries, including dentistry, to a screeching halt. As researchers and public health experts initially scrambled to determine how the virus spread, dentistry became one of the most vulnerable professions. On March 16, the American Dental Association issued a statement recommending dentists keep their offices closed to all but urgent and emergency procedures for three weeks, and to follow state and local guidelines.

“The ADA believes individual dentists should exercise professional judgment and carefully consider the risks outlined in the ADA’s interim guidance and weigh those risks against any possible benefit to the patient, the practice employees, the community at large, and the practitioner,” wrote the ADA. “The safety of their patients, staff and themselves should be foremost when dentists exercise their professional judgment...”

Then, in an unprecedented announcement on March 19, Gov. Jay Inslee signed an order prohibiting “non-urgent procedures that require medical and dental professionals to wear personal protective equipment” until May 18. The impact was staggering and immediate for the profession: In the weeks following, patient volume plummeted.

How bad was it?

By the first week of April, the vast majority of WSDA members reported their patient volume was less than 5 percent of typical volume (source: ADA Health Policy Institute). Over 95 percent of members had to stop paying staff or only partially pay during that same timeframe. Collections were off significantly in the spring, too. And while patients have gradually returned — the vast majority have for Dr. Bradshaw’s practice — there’s a small subset that may have other health factors that keep them away.

For how long, though, no one is certain.

STAFF AND PRACTICE MANAGEMENT

Once the shock of the situation dissipated, dentists statewide were scrambling to address the immediate staff and operational challenges posed by a forced closure. Staffing issues, already tenuous with a short supply of hygienists and assistants, were only amplified by the pandemic and the combination of state unemployment, federal stimulus checks and childcare shortages.

Some employees wanted to stay “laid off” due to the extra $600 weekly federal unemployment benefit. This was very disappointing to some WSDA members and made it challenging to comply with the SBA’s Payroll Protection Program (PPP) loan/grant requirements.

“Retaining staff and keeping them happy is the biggest issue we had to face as small business owners,” said Arlington dentist Dr. Bakhtiar Pribadi. “We cannot compete with the federal and state’s unemployment cash giveaway and employees’ morale and attitude plummet when we force them back to work, sometimes with lower pay than unemployment.”

“There are tremendous demands for all team members,” wrote another respondent. “With a shortage of people even willing to work, especially when they may make more on unemployment, it is a challenge to hire. In addition, we are looking at how we may need to adjust our schedule to assist our employees with childcare/schooling issues.”

And while constantly changing rules and health regulations proved frustrating, if there was one consistent concern among dentists during the pandemic, it was the lack of hygienists — a problem that existed before the pandemic and was only amplified by it.

“We really need to focus on educating the auxiliary staff,” wrote one dentist. “Hygienists are so short in supply that it is ridiculous.”

“We need to expand class sizes in existing hygiene schools and make more schools,” wrote another anonymous respondent. “There needs to be a greater supply. The patient’s oral health is dependent on this as dentists cannot always spend an hour educating patients.”

Dr. Max Saxena, who practices in Bellevue, said fighting the fear and misinformation about the virus also made staffing a challenge and kept many patients away once offices were allowed to re-open.

“One of the biggest challenges has been to deal with the fear around coronavirus and the practice of dentistry,” said Saxena. “People have been very scared coming to the dentist and instilling trust in our patients and calming their fears have been one of the biggest challenges we’ve faced.”

Still others found the financial strain incredibly stressful, forced to make tough choices about staff to preserve the long-term health of the practice.

“I’ve been in practice for over 25 years; our staff is our extended family,” wrote one dentist. “Having to lay them off was a huge mental strain. Thankfully they were able to get unemployment and all were OK financially. Then there was the concern that if this went on too long, I would need to raid retirement savings to keep our practice alive.”

PPE

Three little letters, one big challenge.

Supply-chain delays and immediate shortages of Personal Protective Equipment or “PPE” were real and concerning, especially in the early days of the pandemic. Those who may have had an already adequate supply prior to the outbreak often donated their resources to area hospitals and first-responders whose supplies were running low. Face shields, gowns, gloves and masks — the demand far outstripped the available supply

The lack of equipment, coupled with last-minute changes in PPE requirements, added to the stresses for dentists and have many rethinking supply ordering and inventory management.

Knowing what they know now, dentists like Dr. Christopher Jean of Everett and Dr. Ronald Hsu of Camas said they would’ve definitely ramped up their supply levels for caps, gowns, masks, disinfectants. Hsu wrote that he should have started this process “early and gradually, and placed orders earlier and more frequently.”

In May, the WSDA, in conjunction with the ADA and Delta Dental of Washington, secured 300,000 masks — 150,000 KN95 masks and 150,000 surgical masks — from the Washington State Emergency Management Division for distribution to Washington dentists. This shipment of masks was enough to give 50 masks (25 of each type) to every actively practicing dentist in the state.

Volunteer dentists and component leaders from around Seattle spent nearly 12 hours repacking thousands of boxes of masks for distribution. The following day, dentists picked up masks drive-thru style at the WSDA office in Seattle’s Fremont neighborhood, where a line of cars could be seen stretching down the street.

“We wanted to get these masks into the hands of dentists as soon as possible,” said WSDA Executive Director Bracken Killpack. “Many offices had patients scheduled as soon as offices were allowed to re-open, but for some, PPE supplies stood in their way. The turnaround time was incredible — the shipping truck arrived at the WSDA office on Friday morning, and masks were distributed to thousands of dentists by Saturday afternoon.”

For dentists who could not pick up their masks in-person in Seattle, component society leaders stepped up, transporting masks up and down the I5 corridor and across the mountains to eastern Washington.

WSDA eventually secured over 1 million free masks for Washington dentists, partnering with California-based The Dentists Supply Company (TDSC) to ship masks more efficiently by mail.

WSDA is staying actively involved in PPE procurement so long as pandemic-related disruptions continue. Killpack has been involved in joint public-private sector discussions around PPE procurement with other leaders from health care organizations, emergency management departments, and philanthropic groups. He is also in a leadership role within a group of Washington health care organizations looking to make group PPE purchases in order to reduce costs and increase access to PPE across the state.

THE FUTURE OF DENTISTRY

Today, dental offices around the state have adapted to the “new normal” of the COVID-19 pandemic, practicing with increased infection control protocols in place and ensuring all office staff wear personal protective equipment of varying degrees.

The pandemic has also pushed the health benefits and importance of dentistry to the forefront of public policy.

In an Aug. 12 statement, the American Dental Association (ADA) pushed back on interim guidance from the World Health Organization (WHO), which recommended dental care be delayed in certain situations due to COVID-19. The ADA Board of Trustees adopted its own interim policy stating that dentistry is essential health care and the ADA House of Delegates considered it as a resolution during its virtual meeting in October.

“Whether it’s the current pandemic, a future epidemic or a natural disaster in a particular area, this policy recognizes the need for people to be able to continue to access the full range of dental services,” said ADA President Dr. Chad P. Gehni. “Oral health is integral to overall health — staying well depends on having access to health care, which includes dental treatment.”

“Beyond teeth and gums, the mouth also serves as a window to the rest of the body and can show signs of infection, nutritional deficiencies and systemic diseases,” he said.

“I don’t think it’s going to transform how we practice or what we do. I think things will slowly return to where we were before but probably a little higher level in the immediate future, maybe one to three years,” said Bradshaw. “The biggest effect is that our economy has been devastated by this. We are seeing patients who have the needs of a couple of crowns but can’t afford to get them fixed. That’s going to be the biggest effect — how quickly can our overall economy bounce back? When patients are facing a choice between paying their mortgage or crowns?” he said.

“It’s not going to affect just dentistry, but everything else.”

Of those who responded to the WSDA member survey, several indicated that they would be seeing fewer patients, shortening hours and integrating more part-time staff as a result of COVID-19. Some desire to see better technology emerge to improve the practice of dentistry.

Others are focusing on the financial lessons from COVID going forward. “It’s very challenging to create new emergency operating savings right now, but I will have some different financial systems in place,” wrote one respondent.

“My hope is that dentistry can continue to be open and provide care for patients,” said Dr. Julie Kellogg of Walla Walla. “I feel this will vary regionally. I do worry that we have not yet seen the economic effects and that this will also create a slowdown in dentistry. I am also concerned about the lack of assistants and hygienists. Our veteran team has all come back and are working very hard. But three months in, physical break down and emotional burn out were becoming a real concern,” she noted.

“I also hope that we can get better reimbursements. The stress of what we are doing for such low insurance reimbursements is not sustainable,” she added.

“I think this pandemic shows just how important an emergency fund is for us young dentists,” wrote Dr. Joe Vaughn of Seattle. “We get out of school and see that large student debt we owe and we try and throw every spare dollar we have at that debt. But this has been a very humbling lesson in personal finances and how important it is to consider the big picture and always plan for the worst-case scenario.”

SOME BRIGHT SPOTS

Despite some very uncertain and troubling times, there were some benefits to the work break imposed by COVID. Many said they spent quality time with their family, helping children with online/remote learning and training new pets.

“It was good for my soul and I was able to create some great memories that I would not have been able to do without this time off,” wrote one respondent.

“I learned to roll with the punches,” said Dr. Mikaely Moore Fujita of Auburn. “The schedule is changing constantly.”

For Arlington’s Dr. Pribadi, the break provided extra time to think, learn and grow professionally.

“The work break allowed me to recharge, reorganize and rejuvenate my practice. During the break, I had a 50% attrition of my staff. I used this opportunity to completely understand my practice from the very minute detail, and learn and train myself on every staff’s duties so that I may be able to rehire the right staff that can get the job done how I need it to be done.”

The lock-down also allowed dentists to resume exercise routines and focus on personal wellness, things they may have put off for themselves before the pandemic. And lots of CE credits were acquired online.

“This time was essential in working on increasing knowledge base and keeping current,” said Vancouver dentist Dr. Vaughn Teuscher.

All things considered, despite — or perhaps as a result of — the COVID experience, Washington dentists seem even more committed to what they do, who they help, and their profession.

“[I hope] that we come together as a profession, protect those practices that are not doing well by identifying the individuals who are struggling,” said Dr. Munib Derhalli of Vancouver. “We need to be a community of support for our colleagues and directly impact those charitable organizations within our communities.”