Bouncing Back During COVID-19

Do you consider yourself a “dental” war veteran? If not, the experiences of 2020 may change your mind. Many retired and practicing dentists of more than 30 years have weathered previous battles in dentistry, such as the acquired immunodeficiency syndrome epidemic of the 1980s. As these dental vets were thrown into the trenches, there was little choice but to adapt as new protocols, such as universal precautions, were introduced.¹ With COVID-19, we find ourselves in a comparable war that has wounded many practices along its course.

Fear, often based on incorrect information and lack of knowledge, is enough to keep many patients away from the dental office even though oral health professionals are following new guidelines to keep staff and patients safe. Implementing these guidelines has also significantly raised costs while reducing revenues for dental practices.² The novel coronavirus has brought insecurity—an unfamiliar feeling—to the dental profession. Like many other industries, some dental offices are now in a financial battle for survival. Due to state restrictions and limitations, many dentists have had to furlough or lay off dental hygienists, dental assistants, and front office staff while waiting for business to resume as usual. In addition, unforeseen challenges have caused many practices to apply for government financial assistance through the Small Business Administration (SBA) and Paycheck Protection Program (PPP) just to stay afloat. As the guidelines continue to  change, dentists of all experience levels are being forced to develop innovative strategies to deal with this new environment. However, the big question remains, “What is the new normal?” Once this new normal is established, deciding what adjustments are needed to make the transition as smooth as possible will be necessary.

The purpose of this article is to let oral health professionals know they are not alone. It describes the experiences of three dentists at different stages in their careers.

Hayden C. Smith, DDS: Recent Graduate and Solo Practice Owner

After recently graduating from the University of Tennessee, I have discovered that many trials and triumphs exist within the private practice environment. Obstacles, such as having complete staff turnover and patients changing offices, were just a few examples that came with being the new guy on the block. On the other side, we have seen consistent growth, as we have remained focused on the vision and goals we initially set. I have spent several long nights in thought as I contemplated the inconsistencies and the intricacies of my practice. The saying “They don’t teach you this in school” has played over and over in my mind during the past 2 years as I’ve dealt with many issues outside of my control.

When the uncertainties of COVID-19 emerged, I had to make some quick decisions regarding my practice’s structure. Like many other offices, we were forced to halt all routine procedures and only treat emergency patients. For 8 long, stressful weeks, we opened the office 2 days a week to help those patients in pain and need. During those weeks, we would get daily updates, recommendations, and mandates from governing bodies about changes they were implementing. This constant “stop and go” period brought much frustration, as the phasing and reopening dates were extended. On the financial side, bills continued to find their way to my doorstep. With more than $900,000 in debt (student, practice, and home loans), anxiety and worry brought their own battles. To my surprise, the SBA took over my practice loan payments in April and will continue to do so through September. Fortunately, I was also able to acquire a PPP loan to help with business costs. Although the rules and terms have changed over the course of the PPP loan, I have been able to use it solely for payroll. Remaining faithful with daily prayer, I have no doubt that the Lord will continue to provide as he always has.

Once the green light was given to return to normal operations, we proceeded with caution as we eased back into true patient care. For the first 4 weeks we worked 10-hour days, 5 days a week. This allowed us to schedule and treat patients who were long overdue and boost overall production. Working overtime gave us momentum and a huge gain in terms of production per hour. Some patients were hesitant about coming in for appointments, while others were eager to visit the office. Nonetheless, I believe we made up for lost time with our temporarily long workdays.

Fast forward to present, we are currently working 36-hour weeks. Production and patient scheduling have been fantastic. With continued uncertainty regarding COVID-19, we have, surprisingly, continued to see an increase in new patients. The staff and I are becoming more efficient as we learn to cope with this “new normal.” As positive cases continue to rise, we remain dedicated to taking all precautions necessary by limiting traffic and maintaining effective hygiene protocol throughout the office. On the bright side, our profession will not cease to exist. No matter what occurs, dentistry will always be very much constant. We may experience minor setbacks, but we are here to stay. The simple fact is that teeth will always need attention. I am also thankful that we have a profession that strives to keep its members informed and protected. For those of you who are fresh out of school and have shared these obstacles, keep pushing forward. We will conquer this battle together.

Associate Dentist Seeking to Become A Solo Practice Owner

After graduating from dental school and completing a pediatric dental residency, I decided to work as an associate in public health in a rural southern town. This gave me an opportunity to help underserved populations, including minorities like myself, and also participate in public health loan repayment programs to reduce the burden of my student debt. After nearly a decade in dentistry, I have learned a lot about the art of treating incredibly young patients. With that being said, I thought it was time for me to enter the next phase of my professional career and become a solo practitioner. My desire to pursue private practice was motivated by four goals: to control my own schedule, create a good work-life balance, perform more procedures I enjoy, and provide continuity of care to pediatric patients ranging from infants to late adolescents.

During the initial planning phases of my future independent practice, I exercised due diligence to reduce the stress and uncertainty as much as possible. In the fall of 2019, I hired a private-practice consultant to help me navigate this project and a certified public accountant to assist with the business plan and securing a loan. After finding a location with good demographics, I was finally able to envision the achievement of my private practice dream. My business plan was finalized on March 2, and, on March 16, the American Dental Association recommended that all dentists postpone elective procedures due to COVID-19. This announcement was a crushing blow for me, and over the ensuing weeks I kept asking myself, “How could this happen right when I was so close to making my dream a reality?” I was confused, angry, anxious, and disheartened. I had invested countless hours and money to ensure the success of my initial endeavor, only to see not only my dream deferred, but to experience firsthand the economic fallout of the pandemic by being furloughed.

Disappointingly, my consultant and accountant recommended that I wait to obtain a loan to open the new office. The decision was based on several factors, including the unknown future of pediatric dentistry, dental office personnel being furloughed or terminated, closure of offices, unemployment, loss of health insurance, and dental care affordability. Also, the federal government’s PPP was not designed for dental professionals who wanted to start a practice; therefore, I would not qualify. Considering this sound advice, I reflected on the risks associated with opening a private practice amid a pandemic. How would I acquire N95 masks and air purifiers in the middle of a shortage? How would social distancing in an emergency care scenario work in which any person-to-person encounter is a potential exposure? Lastly, how do I maintain a practice when individuals are told to shelter in place, even with medical exceptions permitted?

Now several months into the COVID-19 pandemic, new protocols have been adopted. All staff members must wear masks throughout the the day and all providers are required to wear personal protective equipment (PPE), such as head coverings, masks, face shields, and gowns. Standard COVID-19 forms now require completion by parents/ guardians and are then reviewed by providers prior to the patient’s visit. Parents are instructed to wait in the car until they are called to enter. Temperature checks are routine as patients and parents enter the lobby. All parents and any child age 2 and older must wear a mask. Every child receives a mouth swab of a peroxide solution before the examination and radiographs. Prophylaxes are performed using a toothbrush and scaling is done with hand instruments. Patients must again don a mask before leaving the clinic. Our patient population has decreased by 30%, and the average patient age has increased from 5 to 7.

I do not regret postponing my plans and I am grateful for the sound and honest advice I received. I genuinely believe it would have been difficult, if not impossible, to sustain a new practice during this unprecedented time. I have decided to lead with a mature and positive attitude about my decision and to use this opportunity as a learning tool regarding office design and layout for the future. Ultimately, timing was the important factor that facilitated my decision. My dream is not destroyed but rather deferred. I am grateful to be healthy and able to enjoy doing what I love: pediatric dentistry.

Joseph C. Griffin, DDS, FAGD: The Mid-Career Dentist Who Is a Solo Practice Owner

My original intention coming out of dental school in 1998 was to begin as an associate and work toward becoming a partner in a two-dentist practice over time. As fate would have it, I became a solo practice owner in 1999 in a town just 7 miles from where I grew up in Mississippi, which is where I remain today. As with any private business, there have been many ups and downs over the past 22 years, but the good has far outweighed the bad. The decade leading up to the COVID-19 pandemic had been one of steady growth; however, in the late spring of 2020, it became obvious that my practice would be greatly affected. During the start of 2020, my practice had the best quarter ever. I had never closed for any appreciable amount of time, and then to have a shutdown practically mandated by local and state governments was surreal.

It was late March when the fear of a shutdown became so realistic that I applied for financial assistance from the SBA. I also realized that we would need additional PPE if we were allowed to resume regular dentistry. Thus, I started trying to acquire as much as I could, while at the same time donating to local physicians. April 2020 was the worst month in the history of our practice—both in dental procedure production and staff morale. We furloughed our entire staff at different times during the month. I also applied for a PPP loan. I missed out on funding in the first phase and that was very stressful, but I received funds in the second phase. The PPP loan proved to be immensely helpful in keeping my practice solvent.

As we could not see nonemergency patients in April, we began planning for when the office could reopen at full capacity. Taking advantage of this time, we looked at our previous practice systems to see where we were being inefficient. We did efficiency group projects with our limited staff on the assumption that a reduced patient load would occur until late summer. My office even planned a huge marketing campaign to allay patients’ fears and to encourage people to come back. We assumed patients would be unlikely to return without considerable reassurances. Surprisingly, we found that the patients in our area were not very fearful about re-establishing a relationship with our office. In fact, they were almost fighting to get back on our schedule. During the month of April with the extremely limited amount of care we could provide, we were running at approximately 20% capacity of our normal patient flow. May 2020 greatly improved as some of the regulations were lifted in a phased fashion, which allowed my practice to approach 75% of our normal production. We brought back most of our full-time staff during this month. June 2020 was one of the best months we have ever had. In fact, it was in our top five all-time production months as we could practice normally for the first time since the pandemic began.

There have been several challenges along the way, particularly the hassle and cost of procuring additional PPE that our state has mandated. Luckily, we acquired enough to reopen to elective procedures in May, but it has been extremely difficult to purchase and very costly. We are spending approximately 5% extra on PPE costs to date. We have not yet increased patient costs to cover the additional overhead regarding PPE. I have based that decision on trying to keep a positive public perception during these trying times. This does not mean, however, that I won’t increase our fees at some point to cover the additional cost. Time will tell.

Looking back, I do not know what I would have done differently. If I had known that we would be able to practice dentistry in a semi-normal fashion back in April 2020, I could have saved myself a lot of worry. However, at that time, no one knew the future. During these challenges, we accomplished two important goals. First, we solved the patient volume problem by June, and hopefully beyond. Second, we improved staff morale and preparation with purpose and focus, enabling them to feel more comfortable and less fearful. In my opinion, the benefits of my team coming together to solve problems were more significant than the logistical gains we made. Just like many dentists out there who have been practicing for a couple of decades, regular practice had become somewhat mundane. I did not fully appreciate the gift that we all have. In our chosen profession, we undeniably have the opportunity to both help people solve their problems and earn a comfortable living at the same time. This pandemic taught me to never take that gift for granted again.

Conclusion

These unchartered waters have left us searching for solutions to overwhelming challenges. The pandemic has been a huge roller coaster that has affected oral health professionals and patients differently. Since March 2020, many providers have overcome the challenges posed by this widespread crisis, but, unfortunately, this has not been the case for everyone. Some providers have had to close their doors or proceed with early retirement. We now know more about how to provide safe and effective dental care during this unforeseen pandemic, but there is still more work to be done. As we have all been affected by the pandemic, sharing and learning from our experiences allow us to make our profession stronger by working together. We must acknowledge the many positive opportunities that lie on the other side of these negative circumstances. Only once we realize that we are stronger together with the mindset of “your battle is my battle” will we prevail.

References

1. Feinberg E. A short history of modern dentistry, infection control. Available at: edwardfeinbergdmd.com. Accessed August 28, 2020

2. Lanni P. Dentists face the coronavirus, and patients’ fear, as they reopen for elective procedures. Available at: nj.com. Accessed August 28, 2020.