200402ind Dentist

Dr. Joseph DiSano, of South County Smiles, is pictured in his office, which has been closed, except for emergency procedures, due to the coronavirus.

Dr. Joseph C. DiSano never expected that suddenly — in a matter of just days — his entire staff would disappear along with most of his patients. He also never expected that a virus would take them from him.

“I miss them terribly, our staff is like family and our patients as well. That whole component is a big part of my life and they’re just gone,” said the owner of South County Smiles, whose brother and father have served the region as dentists.

With Coronavirus protections and precautions hitting Rhode Island hard, they brought temporary closing of various businesses. DiSano and hundreds of dentists statewide — thousands nationwide — have silenced drills, laid off staff, put away instruments and turn on the lights only for emergencies.

Severe restrictions and fears among patients have brought their practices to a standstill. This created a need to develop strategies for retaining patients and their interest in oral health. Underneath this is another concern that some people might drift away.

In addition, patients losing jobs and insurance coverage, some depleting savings, face financial crises from a roiling economy and this will affect patients’ ability to pay as well as the businesses and incomes of dentists, said many in the dental field.

“This is going to be hard on everyone, but I am confident that South County Smiles will weather this storm. We pride ourselves on caring for our community and will look to do our part in giving back. We have tremendous faith in a positive outcome,” said DiSano.

Another local organization also serving dental needs is Thundermist Health Center on River Street in Wakefield. With a community-focused approach, it aims to help many area residents with challenging economic circumstances and in low-income households.

This full-service primary medical care provider also offers dental and behavioral health services. Like DiSano’s South County Smiles, Thundermist aims to supplement other gaps from dentists who cannot treat emergencies during this time when the Coronavirus concerns and have shuttered practices even for the most critical problems.

“We are working hard to ensure access to urgent oral health care for anyone in the state that needs it,” said Dr. Eric Prosseda, Thundermist’s chief dental officer. “We know many private practices may not have the capacity to offer urgent dental care during this period, so we want to get the word out that we are here and ready to help,” he said.

An emergency would be something life threatening like uncontrolled bleeding, severe swelling, or trauma, but both dentists said they now also treat urgent problems, conditions that cause severe tooth or gum pain and infections.

An abscess and painful toothache would be considered urgent or an emergency while replacing a crown or getting a cleaning is not in that category. The Rhode Island Dental Association has accented that point.

“The most important thing dentists can do is to keep patients with dental emergencies out of our hospital emergency departments. During the best of times, hospital emergency departments have no capacity to treat dental emergencies,” said Dr. Steven Brown, longtime RIDA board member.


Reasons for Closing Offices

Dentistry involves the use of rotary and surgical instruments, such as handpieces or ultrasonic scalers and air-water syringes. They create a visible spray that contains large-particle droplets of water, saliva, blood, microorganisms, and other human debris.

This spatter travels only a short distance and settles out quickly, landing on the floor, nearby operatory surfaces, on dental health care personnel (DHCP), or the patient. The spray also might contain certain aerosols, too, said the Centers for Disease Control summarizing the normal conditions in most dental offices.

Caring for any patient requiring transmission-based precautions — needed for anyone because the Coronavirus is highly contagious — is not possible in most dental settings. They are not designed for or equipped to provide this standard of care.

For example, many dental settings do not have airborne infection isolation rooms or single-patient rooms. They also don’t have a respiratory protection program and do not routinely stock N95 respirators, according to the CDC.

Instead the CDC has recommended that dental services should be limited to urgent and emergency visits only during this period of the pandemic. These actions help staff and patients stay safe while also preserving personal protective equipment and patient-care supplies.

This recommendation follows, according to the CDC, the Centers for Medicare & Medicaid Adult Elective Surgery and Procedures suggestion to limit all non-essential planned surgeries and procedures, including dental, until further notice.

While they are following this guidance now, Thundermist and DiSano said that they also took significant precautions in their everyday dental services before the viral pandemic started.

“Dental providers use personal protective equipment all day, every day.  We know how to put it on and take it off.  We know how to clean rooms and sterilize instruments,” said Prosseda.

DiSano explained in more detail how his office handles the issue.

“South County Smiles has always been dedicated to following all infection control practices making it mandatory that all clinicians and providers are wearing surgical gowns and masks and protective eyewear during any aerosol producing procedure.”

He said they also have patients use pre-procedural antiseptic mouthwash rinses prior to all surgical procedures to help minimize the microbial count. Clinicians also handwash when entering and leaving a room where patients are treated.

“We also are focused on disinfecting our waiting room and front desk area on a regular basis, multiple times throughout the day. At this time, we plan to continue following our already implemented procedures and continue to adapt to any changes recommended by the CDC and or American Dental Association,” DiSano said.


Teledentistry and Triage

Like colleagues in general and specialty medicine, DiSano is now turning to the internet and online programs to help patients stay connected with his office. He said that his group has a smartphone, tablet and computer app for teledentistry through which patients send secure emails with photos of their teeth or problem area for an exam without needing an office visit.

Teledentistry refers to the use of telehealth systems, including a broad variety of technologies and ways to deliver virtual medical, health, and education services.

It can involve live video between a people, such as patients and caregivers, and dentists. It also involves the transmission of recorded health information (radiographs, photographs, video, digital impressions and photomicrographs) through a secure electronic communications system to a practitioner

The treatment of patients who receive services via teledentistry must be properly documented and should include providing the patient with a summary of services.

DiSano is among some of the more technologically brave practitioners are venturing into this new are teledentistry. He and other dentists in his office, where they’ve laid off about 20 staff members, are using it for emergency calls.

“We give them instructions,” DiSano explained, “on which angles to take the photos and then they send them to us for a diagnostic exam. We then use face-to-face teleconferencing for any discussions and other assistance for patients in the comfort of own home.”

 Individual consultations will be done in a four-hour time block each weekday on general issues, he said. Dr. Giuseppe Cicero, the dental group’s periodontist and specialist in implant dentistry, created an introductory video about teleconsultations and it will be posted soon on the South County Smiles website.

Thundermist is reviewing the potential to use teledentistry, but right now patients are either handled by telephone or scheduled to come in, said Chief Dental Officer Prosseda. He pointed out that video conferencing with patients is used for medical services.

DiSano said he is also taking the teledentistry a step farther with “town hall” educational programs.

It keeps patients informed about dental care, answers general questions for a large audience and helps keep his business in front of many patients when it could become lost in the darkness of a shutdown and lit up for the few needing emergency treatment, he said.

Cicero also recently crafted a webinar-style information session, which attracted more than 900 other practitioners, about bone regeneration and implant placement. DiSano said that kind of live informational video webinar is the model general weekly educational sessions for the public and patients.

The level of effort to produce the videos and even teledentistry involves learning the technology platform and office professionals’ volunteering their time to host or record them, DiSano said.

“It’s going to be one of those things, after all is said and done, of seeing how it works and bringing new ways of reaching patients and we want to be innovative,” DiSano said.

In addition, he said he also sees the possibility ahead of other changes for dental practices as a result of the Coronavirus.

“We anticipate that this will transform the practice of dentistry going forward in many ways. There will likely be a recommended change in the level of personal protection equipment required by clinicians,” he said.

He said that patients might also see screening for fevers, moves toward an increasingly paperless office to avoid the passing of paper forms between patients and staff, and new online or text payments made directly through an encryption thus minimizing countless potential cross contamination encounters.

In addition, there could be a push to keep waiting rooms sparse, he said, including a “curbside waiting room.”

“One thing that we have implemented at South County Smiles is a Curbside Waiting Room. This is where a patient can check into the office from their cell phone when they arrive at the parking lot and then be notified as soon as their dental chair is ready,” DiSano said.

“They would then enter the office and be escorted directly to the treatment room. The days of large crowded waiting rooms will likely come to an end,” he added.


Patient Financial Problems

With the virus bringing layoffs of thousands of employees throughout South County — and some businesses teetering on permanent closings — a financial problem will arise for patients who cannot afford services, several dentists said.

Some dentists are scrambling to address the need that helps patients and their own businesses that cannot afford to lose that revenue. Others, like Thundermist and DiSano, already have programs in place.

Thundermist Health Center accepts all patients regardless of insurance or financial status, it said. The center also offers a sliding-scale discount program for patients with or without insurance and whose income is at or below 200 percent of the federal poverty level.

“We also know many Rhode Islanders may find themselves without insurance suddenly and may not know Thundermist offers care regardless of ability to pay,” said Chief Dental Officer Prosseda.

DiSano said he is also preparing for an increased number of needy patients.

His efforts, he said, could include extended payment plans through third-party lenders and at low interest rates. He said his office already offers a program for those who don’t have dental insurance.

A patient pays $400 a year in a lump-sum payment or $500 for a monthly schedule. Services include a comprehensive exam, x-rays, two cleanings, two fluoride treatments, oral cancer screening, two emergency exams and 15 percent reductions on other dental treatment or procedure costs, a South County Smiles brochure explains.

However, the focus right now is immediate — treating emergencies and helping those most in need and often in pain, said these dentists said.

“We know how important it is to get dental care when you need it,” said Thundermist President and Chief Executive Officer Jeanne LaChance. “Untreated dental issues can turn into major infections. It is important right now to maintain your health and stay out of the emergency room.”

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