What will it take for Dentistry to Beat the Pandemic?
A HE report on how Dentistry is Coping with the Crisis in India
Many Indians consult a dentist only when it's utterly essential. With the surge in the number of COVID cases in India, those who used to consult dentists have also cancelled their appointments.
Take the case of Dr. Omana Rajan, a physician based in Kerala. She has cancelled all her appointments with her dentist in Kochi due to to the pandemic. "There is a clear connection between oral health and overall well-being. But I don't want to take the risk during a pandemic," she explains.
Her chief concerns are the number of patients and staff in the facility at a particular time, whether they have replaced the equipment to reduce aerosols, the time between appointments, disinfection and ventilation procedures and whether the staff is regularly tested and whether patients also need to be tested before the consultation.
Transmission of COVID -19 in Oral Health Settings
Aerosol-generating procedures (AGPs) are widely performed worldwide in oral health care settings. "AGPs are defined as any medical, dental and patient care procedure that results in the production of airborne particles <5 micrometres (μm) in size (aerosols), which can remain suspended in the air, travel over a distance and may cause infection if they are inhaled," states the interim guidance published by WHO on August 3, 2020.
According to WHO, COVID-19 is transmitted mainly three ways in oral health care settings:
Direct transmission through inhalation of droplets generated through coughing or sneezing;
Direct transmission via exposure of mucous membrane such as eye, nasal or oral mucosa to infectious droplets;
Indirect transmission via contaminated surfaces.
Dentistry has invariably been steep terrain for entrepreneurs.
Most states enacted a temporary ban on elective dental procedures to reduce the infection risk to patients.
Dr. Rushi Trivedi, founder of Smile Merchants, a dental chain targetting rural India, admits that its a distressing time. He points out that COVID has further exposed the fissures in the wall of dentistry.
Even before the pandemic, Smile Merchants had shut down a few less profitable clinics and have cut down the number of clinics to three. Trivedi reveals that he is not planning to scale Smile Merchants anymore. "The revenue of areas like Bhiwandi doesn't match the revenue of metros like Mumbai. That's the reason why we weren't able to scale. There was no investor interest in our chain. That's the reason why we have shut down the clinics," he explains.
Trivedi says that dentistry is a financially challenging vocation. "India churns out thousands of dentists every year. It would help if you had financial support from family or practising in a rural area. Even before COVID, the financial situation of clinics was unsatisfactory, and the pandemic augmented the financial problems of dentists at least 10 times. Dental Council of India and Medical Council of India has strictly recommended not to perform aerosol-generating procedures, unless and until there is an emergency. Less than 1 per cent of patients fall into this category. The government is giving a lot of leeway for doctors, and many dentists are starting their practice. Precautions that are necessary for dental clinics is impractical for 90 per cent of the dentists because their operating margin is very slow," he explains.
Cultivating Resilience
Is maintaining social distance a challenge in dental clinics, considering they operate in small spaces?
"If adequate precautionary measures are taken for the entire practice, then the challenges can be tackled," says Dr. Ritu Girdhar, who runs Zenta Denta in Wadala. At her clinic, a comprehensive and meticulous plan is drawn out and executed with strict adherence, ensuring the safety of the patients and the doctor. "This, for example, can be managed well by keeping ample time between two appointments. Strict appointment scheduling and encouraging people to come aloneminimises the chances of exposure. Some dentists have also made changes in their waiting areas. They have installed physical barriers like glass or plastic windows at the reception areas to limit close contact with potentially infectious patients. In the operatory, if the dental chairs are not six feet apart, then two patients are not treated at the same time. Also, patients are very accomodating. They keep appointment timings and also wait in their cars if the need arises," she explains.
Dr. Girdhar points out that droplets, splatter, aerosol generation has always been a part of dentistry, so it does make the situation a little challenging for the dentists. "In the battle between man and microbes, microbes shall always prevail. You can't eliminate them, and you can only minimise them. As doctors, we want to relieve people of their pain but at the same time, not be the hub of infection for other patients and ourselves. Dental Associations have come up with guidelines to restrict the spread of infection. Being confident and following all the protocols is the key," she adds.
The New Normal
Dr. Aaditi Mahajan, the founder of Loop Dental, seconds her views."As dentists work within the confines of the oral cavity, which is laden with many microbes, we cannot wholly evade from aerosols as most dental procedures are the source of it. However, we are adapting to the new normal and trying to shield ourselves using PPEs such as masks, gloves, face covers which is the first line of defence. Use of a preprocedural mouth rinse using H2O2/Chlorhexidine is the second line of defence. High-volume evacuation, Rubber dam, HEPA usage includes the third line of defence which safeguards not just dentists and dental assistants but also the patients".
How can Dental Clinics Get Back on Track?
Dr. Niranjan Prabhakar, South Side Dental, Bangalore says that fear among people is affecting all industries including dentistry."Dentists are taught to deal with infectious diseases like HIV and Tuberculosis. We wear mouth masks, protective eyewear, head cap, gowns as a norm. And also provide the same to our patients. We treat every patient, as they may be having these problems. American Dental Association has come out strongly against the connection between dental aerosols and COVID. They have also said that they haven't found any connection between COVID and dental aerosols. COVID-19 is a very new problem. International bodies have been right about deferring the treatment. There's a possibility of spread if dentists don't take precaution, but the majority of dentists have invested in equipment and SOPs that can safeguard patients and doctors," explains the periodontist.
There is a 30-minute gap between appointments at South Side Dental, where staff wipe down all the surfaces that the patient may have touched. Chairs and floors are sanitised with disinfectants. Windows are kept open for air circulation.
Revenue come down by more than 50%
"Dentistry is an extremely unpredictable business as it relies on imports of dental materials and how they are supplied and distributed. Many dentists spend 2X or3X on disposables now, and the revenues have come down by more than half now. The price of essential items for clinics like mouth masks shot up drastically after COVID. A box of gloves which used to cost Rs 200 became Rs 600. But many clinics have increased the consultation fee only minimally," explains Prabhakar.
What about telemedicine? "It doesn't work so well for dentistry," says Dr. Lakshmi Roopesh, founder of Dental Den, Bangalore. "We are part of platforms like Practo. So, the option of teleconsultation has been given to patients. But, the maximum treatment is usually a pain killer for an online consultation. During the lockdown, when we were shut down, a couple of patients had to take three courses of antibiotics. How fair is it for the patient to go on three courses of antibiotics, where we are indirectly compromising the immunity of the patient. Online consultation is definitely not a way forward for dentistry," she concludes.