COVID-19 IS CHANGING DENTISTRY

The most dangerous aspect of COVID-19 is asymptomatic transmission by the apparently large minority of the population that carry the virus but do not show any symptoms.

A steadily increasing number of testing studies from numerous countries – Korea, China, the U.K., Italy and the U.S. – confirm that there is a substantial hidden group of infected but non-symptomatic people in the general population. Depending on the country, the demographics and the type of testing, the size of this asymptomatic group ranges from about 15% to 50% of the overall population.

The most recent example of the asymptomatic phenomenon is the Triumph Foods meat packing plant in St. Joseph, Missouri (CNN – May 4, 2020). Triumph Foods undertook mass testing of all the workers at this plant in late April. Of the 1,500 workers tested, 17% were positive for COVID-19. Not one of the workers with COVID-19 showed symptoms! THEY WERE ALL ASYMPTOMATIC !

The reason that asymptomatic people are highly dangerous to the general population is that, because they are not readily identifiable as being infected with COVID-19 due to their lack of symptoms, they do not self-isolate. As a result, they continue to circulate and are exposed in the community. They are the main source of 'community spread' -- infections that public health officials cannot predict, cannot take actions to prevent and that appear without any traceable source.

At a national level, we must successfully implement 2 key strategies to fight COVID-19 before life returns to 'normal': an effective/safe vaccine with mass immunization, and mass testing to identify asymptomatic infectious persons. Until we get to that point, dentistry will be significantly constrained in both the type/extent of treatment provided and the manner of treatment delivery. Because every patient represents a potential asymptomatic infectious carrier, dental regulatory agencies that are mandated to protect public safety must err on the side of caution (i.e., restriction) with practice standards. 

WHAT DOES ALL THIS MEAN FOR DENTISTRY? IN ONE WORD: CHANGE!

In the last 10 days, the Ontario, Alberta and Saskatchewan dental regulators have all come out with new guidance for practice operations as we begin to undertake a slow, phased-in reopening of non-emergency dentistry. The regulatory approach is, to say the least, stringent (that's the politically correct expression). For general practices, there will be potentially major hurdles to overcome in the transition to operating under the new guidance, and then there will be further major disruptions to everyday treatment delivery.

For example, the College of Dental Surgeons of Saskatchewan has published an extensive and detailed Interim Protocol for non-emergency treatment under COVD-19 conditions. The Protocol includes important changes to treatment delivery. All aerosol-generating procedures (AGP) – including all use of ultrasonic scalers, high-speed handpieces, surgical handpieces and air-water syringes – must be done in AGP operatories that "must be isolated from floor to ceiling with an entry or entries that must be closed and secured during the AGP".

The Updated Guidance on Emergency and Urgent Care from the Royal College of Dental Surgeons of Ontario has the same operatory requirements - door and floor-to-ceiling walls - while the AGP is being conducted. Post-AGP, to allow for settling of aerosols and to facilitate subsequent cleaning of the operatory, Saskatchewan requires that the operatory be kept closed for 120 minutes and Ontario goes even further and requires 180 minutes of closure. So, each operatory is out of service for 2-3 hours plus cleaning time after each AGP!

This means that all the modern offices that have operatories without doors and where the walls do not reach the ceiling must be renovated before those practices can re-open. Even basic hygiene appointments involving an ultrasonic scaler must be undertaken in an AGP operatory - with a door and floor-to-ceiling walls. This not only restricts the delivery of treatment, it generates potentially significant renovation costs, delays the re-opening of the practice and damages the financial condition of the business.

All of the new Provincial guidance - from Ontario, Alberta and Saskatchewan - add significant requirements for hospital-operating-room-style PPE for all personnel while in the operatory. Saskatchewan sets the bar highest, stipulating that "the standard should be to provide the highest level of PPE". Saskatchewan requires that there be an independent area (ante room or separate hallway area) for donning and doffing PPE, together with a special area for disposing of it. All of this will involve time and expense for repurposing (i.e., renovating) space in the office, additional expenses to obtain PPE and may also cause delays in reopening practices because adequate supplies of PPE are not readily available in the dental sector.

In addition, there are new requirements for "managing patient flow". The guidance from all of the Provinces - Ontario, Alberta and Saskatchewan - indicates that practices are to "reduce the number of appointments", "stagger appointment times to facilitate physical distancing between patients" and "reduce waiting room exposure" by having patients wait outside the office in their car. This will significantly reduce the volume of procedures, will cause an equally significant reduction in production and practice revenue, and will further damage the financial condition of the business.

Consider the operational impact of the new full-hospital-style PPE requirements. These apply not only to dentists, but to all other operatory personnel including hygienists and assistants. General dental practices have never functioned with this level of PPE; staff aren't used to its weight; how cumbersome, hot and uncomfortable it may be; and how difficult it can be to adjust to working with it. The days of a morning full of back-to-back appointments are gone: dentists, hygienists and assistants will need breaks between appointments not only to change PPE in accordance with the professional standards of practice but also for their own preservation. As a result, production and productivity will decline, profit margins will get thinner, cash flow will weaken, and it will be more difficult to service the bank loan that was used to acquire or build the practice.

Lastly, consider the impact of all of this on the value of the dental practice. This will not become apparent immediately, because the appraiser/brokers have a vested interest in trying to maintain some semblance of price stability in the market. But it will become apparent as time goes on. Objectively, appraisers will need to see final guidance from the appropriate regulatory authorities for "non-emergency dentistry" so that we know what the operating environment will be for general practices. Not all of the short-term emergency restrictions will continue, but some of them will out of a regulatory abundance of caution. Then the chickens will come home to roost. It is impossible to escape the inevitable conclusion that the value of practices will decline when: (1) revenue declines; (2) expenses increase; (3) operating cash flow (EBITDA) declines; (4) net profit declines; (5) ability to service bank loans declines, causing defaults on loan covenants and loan payments; and (6) demand will decline as prospective purchasers view ownership less positively.

WE ARE LIVING THROUGH A FUNDAMENTAL CHANGE IN DENTISTRY. Practice ownership now brings additional medical responsibilities and potential legal liabilities. Operating conditions are becoming more difficult. Financial rewards will diminish. Dentists who can successfully adapt will survive and continue. Those who can't, won't.