DENTISTING DURING CORONAVIRUS Part 4: Interview with Dr. Lee Sheldon

In this new series, we’ll be asking questions and getting first-person perspectives on what it’s like so far to practice amid the pandemic. Every region, every practice, every practitioner has unique stories so we’re chronicling them here to give you an up-close and personal look at challenges, solutions and inspiring moments across the country.

Periodontist Dr. Lee Sheldon has been practicing for over three decades, so he has seen a lot of changes. An author and former associate clinical professor, he received his DMD from Tufts University School of Dental Medicine, and his certificate in Periodontistry from the University of Connecticut School of Dental Medicine. His practice, Solid Bite, is located in Melbourne, Florida. His recent article on creating brand awareness for specialists uncovered some startling survey results and offered a plan for countering lack of awareness—timely help as dentistry reopens under complex circumstances. 

Q: When did you reopen your practice?

A: We found out on April 30th that we could reopen on May 4th, but we really didn’t reopen our practice on that date. During the previous few weeks, we started to look at PPE and how we could refigure our practice to make it satisfying to both our staff and patients. We bought some equipment and some PPE. By May 4th and May 5th, we were writing, drilling, and rehearsing our new protocols. I started by giving about a half-hour PowerPoint lecture as soon as we got there on May 4th to let the staff know what we’re doing to make it safe. On Monday and Tuesday, we did not see one patient; we just rehearsed and got comfortable with the protocols. On Wednesday, we saw about half the normal patient load, same on Thursday and Friday. Usually, when you’re putting in protocols in an office, you’re doing it one at a time. But here, we are putting in seven or eight new protocols all at once, so we had to go slowly to do that effectively. By the time we were done on Friday, everybody was really comfortable. On Monday, May 4th, we told patients we were open and the phone started ringing off the hook. From May 11th on, we’ve been going gangbusters—every single day, every single week with a ton of new patients. Even with a slow first week, we had a fabulous May.

Q: What has been the biggest challenge so far?

A: For us, the biggest challenge was deciding what equipment we needed in order to feel like we have everything we need to protect our patients and staff. We have a reception room that holds eight people, but to socially distance correctly, we can only have three people in the room at one time. So they wait in the car until we have the ability to allow three people in the reception room or until we’re ready for their appointment. There was a little bit of difficulty initially doing the histories and taking temperatures. It’s an additional step, but once you’re used to the step, that’s just the way it is.

Q: How have the changes in PPE affected your ability to practice?

A: In general, I think there’s a lot more sweating going on. Unfortunately, we couldn’t get any gowns that were light weight and we had to order food service gowns, which are much heavier. We’re able to get some lighter gowns now so we’re going to throw the heavier ones away and start over. It’s more difficult to breathe in face shields and people are sweating but not to the point where the staff is complaining. You look at it in two ways: mild discomfort versus safety. Even the CDC guidelines don’t say you have to change gowns between every patient, but we’re changing our gowns between every patient. The difficulty was mostly in the planning, but we took the necessary steps to make sure that was done correctly so we can practice the way we need to practice.

Q: How has the experience been with patients? Has it been difficult to encourage patients to come into the office?

A: Almost no difficulty. There were a few patients who told us they’re putting off their visits for a month or two. The steps we took allowed us to see our patients with the same frequency, even in hygiene. The hygienists told us they didn’t need any more time between patients than they were taking already.

Q: Have you encountered any challenges with staff members?

A: No, and I thought we would. Two staff members arrived for that initial lecture and were a little bit reluctant, but once they saw what we were doing and were comfortable, they had no reluctance at all. I think it made everybody feel better. 

Q: Will dentistry ever return to what it was like pre-Covid? Should it? Or are the new precautions justified even in a world with a vaccine?

A: First of all, I don’t think we’re ever going to have a vaccine. We’ve never been successful with a flu vaccine; this will not be any different. We already have a feeling that the virus is going to survive. The virus wants to survive, it’s not killing off as many people as it was before. If the virus is changing, I can’t imagine we’re going to have vaccines that kill every mutation. Do I think it was appropriate to take the mitigation steps? I think it was long overdue. The last time we changed our protocols in dentistry was in 1986 after AIDS. To wait 34 years to change protocols was too long. Unfortunately, there is no standard protocol. We’re doing things that other people aren’t doing and other people are doing things that we’re not doing. We don’t know what is ultimately going to be correct, but increasing the discipline to decrease the possibility of infection and viral contamination is a good thing. Does it cost a little bit more money? Yes. Are we charging our patients $12 for procedures that use aerosols? Yes. We have gotten no squawking from patients when I tell them it’s an additional $12 fee for the particular visit. I think whenever you can put in some disciplines, it makes it safer for the staff. It makes it safer for the patient. I think it was a good thing. I wish we didn’t have this excuse to do it but I’m happy we did.

You Can’t Live Without Them, So What’s The Next Best Thing?

While there’s no way around using handpieces during this pandemic, some may be better than others in terms of potentially mitigating risk. If you haven’t taken a close look at handpieces in a while, here’s a refresher on what to look for.

There’s no such thing as a “miracle” handpiece that generates zero aerosols. However, there are many options in terms of choosing the next best thing, which are handpieces that meet your clinical needs while reducing aerosol generation and the possibility for cross contamination as much as practically possible. Let’s quickly review some features and performance characteristics that make the most sense in terms of we know about reducing the risk of Covid-19 transmission.

A One-Two Punch Against Aerosols and Cross Contamination

Even if you know what the terms ‘anti-suck back’ and ‘anti-retraction’ mean, you might not realize how important their implications are in our current environment.

The issue of suck back first came to dentistry’s attention back in the 1990s. It became clear that air-driven handpieces were capable of transferring microbes from one patient to the next. That’s because, when air flow is interrupted for braking bur rotation, negative pressure can be created that can “suck back” fluids and debris into the handpiece’s air lines. This problem has been addressed by incorporating anti-suck back systems into well-engineered handpieces by reputable manufacturers. 

Not all handpieces incorporate anti-suck back technology. In fact, if you count in all of the cheap, no-name handpieces being sold through auction sites and questionable vendors, probably most of the handpieces worldwide don’t have anti-suck back features. The problem, of course, is that aerosols, fluids and debris that are sucked deep into the handpiece are more difficult to reach and properly sanitize. If the handpiece isn’t properly sanitized, the next time it’s used you’re exposing the patient, yourself and team to potentially dangerous aerosol.

Another safeguard is the use of an anti-retraction valve in couplers and micromotors to prevent water from being drawn back into the dental unit’s hose and water block. Since the hose, water block and valves are not sterilized, contamination presents a huge problem—but only if it occurs in the first place. Anti-retraction technology prevents this from happening, but once again, the higher quality the product, the more effective it is likely to be. 

It is important to note that dental units are required to have anti-retraction features, commonly known as duckbill valves, one-way valves, backflow valves and other names. However, handpieces are not required to have these features. Despite that, the very best handpieces do have anti-retraction built into the handpiece or coupler. Why? It acts as a backup. If the valves built into dental units begin to fail before a malfunction is able to be identified, the valve in the handpiece or coupler acts as a backup parachute of sorts.

An Ideal Time To Think About How Performance Also Impacts Your Safety

Clearly, if your handpieces don’t incorporate anti-suck back and anti-retraction features, you’re increasing the risk of cross contamination. That being said, it’s being reported that infectious disease experts now believe the length of exposure to Covid-19 and the amount of exposure are key factors in disease transmission. The risk would therefore appear to increase the longer you’re actually using your handpiece.

A solution would therefore be to use the highest-performance handpieces (and burs) possible. Doing so means completing procedures in the least amount of time, with the least amount of effort, and with the best clinical result which lessens the possibility that retreatment is necessary. Investing in high-quality, high-performance handpieces generally ensures you’re getting the benefits of not only anti-suck back and anti-retraction features, but also the ability to do faster dentistry that reduces the amount of time you could be exposed to Covid-19. Since dentistry is more time-consuming today, completing procedures faster contributes to meeting production goals as well, which is a welcome side benefit.

The Case For Investing In Quality and Safety

Obviously, low-quality handpieces offer none of the safety and performance advantages we’ve described. They don’t safeguard patients and your team, they don’t allow you to complete procedures as efficiently as possible, and they also may harbor microbes deep inside the handpiece that cannot be effectively neutralized through sterilization. Pre-Covid, we’d simply remind you that they cost you more money in the long run than they save you upfront. Now, however, they add a potential danger factor that cannot be ignored. It’s more important than ever to buy known brands from reputable dealers. High-quality handpieces last longer, perform better, can be relied on for peace of mind and are backed by their manufacturers for longer.

What Else You Can Do

As far as we know, aerosols are our biggest threat right now when it comes to Covid-19, and handpieces play an unavoidable part in generating them. However, in addition to choosing handpieces that address Covid concerns, there are other ways you can potentially ramp up your safety, like:

• Screening patients and doing reduced-contact check ins with stress-avoiding technology like OperaDDS

• Having patients rinse with a hydrogen peroxide or povidone-iodine solution before procedures

• Using dental dams to reduce airborne particles

• Considering the use of chairside extraoral suction

• Implementing enhanced air quality technology

Bottom Line

Benco Dental only sells handpieces by brands we know and trust, from our own Sterling line to exceptional names like NSK, Dentsply, KaVo and more. Now is the time to consider replacing your handpieces if they don’t meet the standards for today’s crisis. Look for the features we described as you browse the latest models in this issue of Big Big Deals. If you have any questions, be sure and reach out to your Friendly Benco Rep for help and answers. At a time like this, when it seems like everything is a little more complicated, choosing handpieces doesn’t have to be.

How will the stimulus bill impact your dental office?

For dentists wondering how the Federal stimulus bill will impact their office, or searching for best practices to stabilize and strengthen a dental team in the midst of the COVID-19 crisis, a webinar on Tuesday, March 31 will provide answers and options.

“The Practice Interruption” hosted at 5:30 p.m. ET will offer expert advice from Dan Wicker, CPA, Cain Watters and Associates partner and managing director, and Dr. Todd Engel, owner and founder of Engel Institute. They’ve teamed with Benco Dental to present this free webinar to assist dentists today, tomorrow and when the practice doors open again.

Register here.

What are the March 31 webinar objectives for dentists?

The Coronavirus pandemic has sparked a frenzied selling of stocks and mandatory lockdowns all over the country. Businesses of all sizes have been disrupted by the virus, as a result of local and national reactions. For dental practice owners, having to close their doors for business quickly carries implications on their personal finances.

Tuesday’s webinar, sponsored by Benco Dental, Cain Watters and Associates and the Engel Institute, addresses those topics and more. Register here.

From Dan Wicker: “Overview of the New Legislation and the Impact On Your Practice”:
* How will the stimulus bill impact my office?
* What do practices need to know?

From Dr. Todd Engel: “Best Practices to Stabilize & Strengthen Your Team, Your Patients and Your Practice”.

Ready to register?

To register: click here.

Have COVID-19 questions? ADA offers extensive resources, webinars for dentists

The American Dental Association is committed to helping the dental community navigate the unprecedented crisis of COVID-19. Their most up-to-date information regarding can be found at ADA.org/virus.

On March 20, 2020, the ADA teamed with leading infection control experts from the Organization for Safety, Asepsis, and Prevention (OSAP) to provide the dental community with practical guidance and education.

The first step: providing extensive resources and webinars. View an entire page of their recorded webinars here

An example of one of the videos: 

Dental professionals are invited to frequently check this page for additional webinars.

On which other topics does the ADA share COVID-19 updates, webinars?

  • Current Infection Control Protocols and Procedures
  • Personal Protective Equipment
  • Sanitizing Operatory Rooms and Equipment
  • Aerosol
  • Pre-Treatment Mouth Rinses and Daily Hygiene
  • Protecting Patients and Dental Staff

And the presenters are…

Kathy Eklund, RDH, MHP

Eve Cuny, MS, the Director of Environmental Health and Safety and Associate Professor at University of the Pacific, Dugoni School of Dentistry in San Francisco, California where she is also Assistant Dean for Global Relations. 

Kathy Eklund, RDH, MHP, the Director of Occupational Health and Safety, and the Forsyth Research Subject and Patient Safety Advocate at The Forsyth Institute. 

Ready for webinars and updates?

Click here.

Cain Watters offers toolbox for dentists managing cash flow, staffing during COVID-19

By Cain Watters & Associates, Registered Investment Advisor // Guest Column

As the country continues to address the implications of COVID-19, we know many of you are uneasy about the coming weeks and months for both your family and businesses. 

Elective closures continue and it is undetermined whether mandated closures will be enacted.  For example, Ohio is requiring rescheduling or postponing elective procedures and Virginia is recommending practices close for two weeks, while some areas are currently seeing limited to no disruption. 

With the landscape changing in varying degrees by geographic region, we wanted to offer our recommendations around cash flow and staffing, as well as additional resources available to the CWA community.

Based on your personal situation, access to cash flow and level of risk tolerance—the ideas offered below are simply suggestions to keep in your toolbox over the coming weeks and months, should you need them.

MANAGING CASH FLOW

Managing cash flow will be essential to get your practices through this time.  Here are some ideas to maintain or increase your cash flow should you need it:

  • Discontinue payroll for the doctor, spouse and any children.  Instead, take only required draws (shareholder distributions) from the business for cash at home.  This will minimize payroll taxes, federal taxes and 401(k) deferrals through this volatile time.  These can all be made up in the future when cash flow resumes.
  • Reevaluate dental and office supply purchases, and consider stopping purchases with exception for those products that will get you through the coming weeks.
  • Call your bank and request interest-only payments on your practice and/or building loans for a period of 1-3 months. Additionally, if you are making excess payments (above the minimum required payments) on any personal or business loan, adjust this until normal cash flow
  • If needed and available, access available lines of credit on the business or personal residence.  If you do not have a line of credit, contact your bank to see if an emergency line of credit could be available.
  • Contact your credit card companies.  Because of your history with these companies, you can request to skip a payment with no penalties or interest.  Additionally, many of your cards may have low interest cash advance options that could be used if needed.
  • Pause any automatic funding to Defined Benefit and 401(k) plans.
    • If your plan is at T Bank, we are working with the trust department to streamline this process.
    • If your account is at TD Ameritrade, you can call 800-431-3500 to stop or decrease automatic contributions.
  • Consider taking withdrawals from personal investment accounts (non tax-advantaged).  If your personal account is at T Bank, liquidations occur on Friday and T Bank does need notice.  As such, do not delay if you want to take a distribution soon.
  • Consider loan options on your 401(k). Loan provisions may allow you to take up to $50,000 for both the doctor and the spouse.  Note:  If your plan does not allow for loan provisions, this can take some time to get done.  CWA is currently working with Peeples and Kohler and The Nolan Company to see how we can speed up this process.
  • Minimize personal expenses. Now may be a good time to sit down with the whole family and discuss how you can minimize spending in the coming weeks.

STAFFING & THE RELIEF PACKAGE BILL

While staff costs are the largest single expense in your business, it is also the hardest to reduce, especially during hard times.  We all care for our staff, but also must manage the business.  The Relief Package Bill 363-40, passed by the House on March 14, is supported by the President and is expected to pass the Senate. 

There are four main areas affecting employers:

  • Emergency paid sick days: The bill would give workers 14 days of paid sick leave available immediately. It ensures sick leave to those impacted by quarantine orders, or those who must stay home to care for their children. The bill reimburses small businesses through a payroll tax credit (those with 500 or fewer employees) for the cost of the 14 additional days of leave.
  • Emergency paid leave: The bill would create a new federal emergency paid leave program for those unable to work because they have COVID-19, are quarantined, are caring for someone with the disease, or are caring for a child due to coronavirus-related school closings. Eligible workers would receive benefits for a month (the program goes up to three months), and the benefit amount would be two-thirds of the individual’s average monthly earnings. Those receiving pay or unemployment compensation directly through their employers aren’t eligible.
  • Small Business Exemption:  Under the current bill, there is an exemption for the above requirements for businesses under 50 employees.
  • Expanded unemployment insurance: The bill would direct $2 billion to state unemployment insurance programs and waive measures like work search requirements or waiting weeks to those either diagnosed with COVID-19, or those who have lost their jobs due to the spread of the virus.

Should the Senate vote to approve, we will know more.  As we get concrete info on the bill, we will communicate further as to how this affects your business and more recommendations on how to move forward.

ADDITIONAL RESOURCES:

We are lucky to work with fantastic vendors that are also here to help.  Here are a few available resources you should find helpful:

WEBINAR: Coronavirus & the Dental Professional: A Critical Update

March 19, 7:30 CST. Sponsored by Seattle Study Club. While general healthcare guidelines are available, Dr. Leslie Fang has modified these guidelines specifically for the dental profession. Don’t miss this live webinar, which will not be recorded.

WEBINAR: Coronavirus Guidance and Updates for Employers

On-demand, available now.  CEDR‘s experts in employee law answer some of the most common questions, from people coming back from travel, sending a sick person home, employees who want to stay home, to getting sick notes from doctors.

FACEBOOK GROUP: Join the CEDR HR Basecamp Facebook group for ongoing information, updates and to ask the experts questions. Only for dentists and medical, it is a free private group which you will need to apply to.

We hope this information is helpful to you should you need it.  We will continue to communicate our thoughts, recommendations and resources as they become available.  Please visit our COVID-19 Resources Page for transcripts of prior communications and additional resources as they come available.

If you have specific questions, please reach out directly to your planning team.

You don’t have to navigate this alone, our advisors are here to help. REACH OUT

About the Blogger

Cain Watters is a Registered Investment Advisor. Cain Watters only conducts business in states where it is properly registered or is excluded from registration requirements. Registration is not an endorsement of the firm by securities regulators and does not mean the adviser has achieved a specific level of skill or ability. Request Form ADV Part 2A for a complete description of Cain Watters investment advisory services. Diversification does not ensure a profit and may not protect against loss in declining markets. Past performance is not an indicator of future results.

Benco leaders discuss masks, infection control products

Managing Directors at the nation’s largest independently owned dental distributor — Benco Dental — recently shared an update with their dental customers and the dental community regarding masks and infection control products.

Below, a letter from Benco Dental Managing Directors Chuck Cohen and Rick Cohen:


“As you’re well aware, the COVID-19 pandemic has led to an unprecedented and sudden worldwide spike in demand for infection control products. Severe supply chain disruptions are impacting our ability to fulfill certain orders at this time. Unfortunately, it will be some time before the situation normalizes.

Here’s what we’re doing right now to help ensure supply continuity for as many customers as possible:

· We are continually refining our methodology for rationing items like masks, gloves and wipes based upon your order history, our current stock, and expected stock.

· We are selling most asepsis products only to healthcare practitioners to ensure that the people who need these essential items most—you—have as much access as we can provide given the circumstances.

· In order to equitably distribute products, Benco reserves the right to ration the quantity of asepsis products being sold. In a majority of circumstances, Benco will only accept orders for asepsis products from existing customers, who had placed an order with Benco for consumable products in 2019.

· We continue to work with our manufacturers across multiple countries to minimize the impact of shortages.

Here’s what you can do to help ensure you get the products you need:

· Contact your Friendly Benco Rep or call 1-800-GO BENCO for the latest information on ordering and quantity limits per product type. The COVID-19 pandemic’s impact on supply chains is fluid and changing by the hour. Because of this, Benco adjusts our rationing procedures as necessary.

Here’s what we know about price increases:

· Benco Dental has never, and will never, engage in price gouging. We will keep our prices steady except when manufacturers increase our costs.

· However, with a huge and sudden spike in demand for infection control products, price increases are inevitable.

· The vast majority of well-known manufacturers are honest and ethical, and they also know that greed is bad for business.

· While we expect prices to rise, sometimes sharply, bear in mind that manufacturers are working to identify suppliers that can keep up with demand for materials, and they’re also responding as best they can to pressure to increase production capacity. Anytime demand exceeds supply, costs rise all down the line. Everyone is doing whatever it takes to keep production lines rolling in the face of a worldwide health crisis. The increases we are starting to see are a result of supply chains stretched to the breaking point at every link.

· As always, when supply catches up, prices will normalize as well.

We understand how difficult this situation is. We’re proud of your commitment to providing remarkable patient care during this crisis, and we want to assure you that Benco is doing everything in our power to secure all of the product we can.
We value your business, we’re grateful for your loyalty, and thank you for your patience as we navigate these supply chain challenges due to extraordinary circumstances beyond our control.”

Benco Dental Managing Directors Chuck Cohen and Rick Cohen