The Dental Industry Prepares for the Next Pandemic

There are plenty of aphorisms about the necessity of being prepared for bad things to happen, but that’s probably because it is such an important thing to do. Businesses must have safety nets in place, but dental practices should be extra vigilant, because they are in the business of caring for others.

Fires happen. Tornadoes happen. And, as 2020 showed, pandemics happen. The world—and, indeed dentistry—is still coping with the fallout of the coronavirus 2019 (COVID-19) pandemic, and it underscores the need to be prepared for the next pandemic, or any other crisis, for that matter.

2020 became the year of infection control. Certainly, infection prevention processes, procedures, and best practices are nothing new, but the pandemic thrust them into a brighter light. It emphasized the need of having good infection control methods in place.

“When it came down to people responding in a pandemic, I always go back to practices having a standard of care that’s written,” Jessica Wilson, MPH, Business Development Manager, Infection Prevention & Instrument Management, HuFriedyGroup says. “That’s their guidebook of protocols when it comes to infection control for patient and provider safety. When you come into a situation, like a pandemic, where something has to change, what you want to look back to is, ‘Okay, what were we doing as a collective unit and what do we need to adjust?’ A lot of practices didn’t have a guidebook for the standard to follow, in general, as a benchmark.”

Some practices are better than others at having that infection control plan in place. An important lesson for practices to have learned from the pandemic is the necessity of having such a plan in place.

“All dental organizations, no matter how big or how small, need to be clear that they have a program in place,” Wilson advises. “Putting together a full program on managing infection control and prevention is about the staffing of the people who are dedicated to managing that program, as well as the methods being used to communicate with people. Dental teams will expect it around something like compliance and patient safety, especially if there are any requirements around the need for monitoring and recordkeeping that may be audited. People need a process to follow. For example, how do you manage changes in a multi-level organization to provide visibility to management for protocols that are in place due to the pandemic?”

An example of enhanced infection prevention measures include patient safety checks when they check in for an appointment.

“Taking temperatures and keeping a log of everybody who walked through the front door is something that requires new protocols for dental practices to follow,” Wilson says. “Well, if you’re not used to having to log something like that, and now it’s in your written infection control program, that is a new policy that is compliance related, and you can create a behavior change as a result. It is easy to identify team members who are impacted, and now you can say ‘send this to me at the end of every week,’ so there is oversight for the new policy, records for any type of contact tracing potential, etc. to manage the information. Maybe you have established all important communication will be provided via email or a text group. What do we do in the event a patient presents with symptoms?”

Although the COVID-19 pandemic differed from “run-of-the-mill” disasters, like fires or floods—and it’s anybody’s guess when or what the next pandemic will be. How the practice prepares should still be the same. It starts with getting the practice’s systems in place, says Roger Levin, DDS, CEO and Chairman of dental practice consulting firm the Levin Group.

“If you have the right systems, and the team is trained in those systems, you’re just going to have better day-to-day results,” he says. “And, certainly, whether there’s a crisis or future pandemic, they’ll fare far, far better.”

“Automate as much as possible,” Dr Levin advises. “The less that has to be done by hand with repetition, the more that can be automated in software and software-like products or technology, the better.

“Number two is to train every team member to their highest potential,” he continues. “I find it interesting that nobody’s really talking about how hard it is to bring new staff members on board. Everybody’s talking about how finding staff is hard, but they’re not talking about the root issue, which is that dentistry has exponentially advanced in services, products, technology, and insurance in the last 10 years. And let’s call this a dental technological revolution. And then, when you go out and hire someone, it is very unlikely that they have all the necessary skills to function in this level of technological environment. Team members in the practice need to receive ongoing training in regard to practice advancement. Many years ago, when I was in practice, one of the practice management ideas was if you needed an assistant or front desk person, you search for the waitress or the bank teller that had a great personality, and you offered them a job. That is not going to work anymore. They just don’t have the background for a dental practice.”

“Maximize the collections system,” he recommends. “Too many practices have overdue accounts. They run loose. When you don’t collect, you don’t have the cash to put away to protect you for the future.”

Ultimately, it all comes down to the practice owner’s business acumen and leadership ability.

“I’ve always said that a good CEO—and dentists are CEOs—both wants to grow the business, but has to protect the business,” Dr Levin observes.

Practices, of course, aren’t islands unto themselves. They work with other professionals, and protecting those relationships is critical for both parties. Dental labs were affected during the early days of the pandemic, because there were few cases coming from dental practices.

“Dental laboratories ride the tide with clinical dentistry,” Bennett Napier, M.S., CAE, Executive Director of the National Association of Dental Laboratories (NADL) says. “During March to May 2020, a considerable number of dental laboratories had to retool their workforce, temporarily, as ‘cases coming in’ at the peak of the pandemic went to 20 percent of normal production. Most dental laboratories stayed open during the early part of the pandemic, as they were defined as essential businesses that were necessary to help dental practices complete emergency cases. Much like any other small business, many dental laboratories utilized different SBA [Small Businesses Administration] programs to help offset revenue declines. The other key elements of impact relate back to wearing of PPE and additional protocols related to infection control for cases coming into the laboratory and the finished case being shipped back out.”

What happened with COVID?

What happened with COVID?

COVID-19 is known as a “novel” virus. That means, it’s brand new and we’ve never seen anything like it before. Not only were practices forced to fight back against the virus with seemingly ever-changing advice from advisory bodies, like the ADA and CDC, but the business side of dentistry was affected by the pandemic in new, unexpected ways.“

The pandemic is different than any other challenge dentistry has ever seen before,” Dr Levin observes. “It’s significantly different. We had a shutdown, which we have never had before in our profession. An individual practice might’ve been shut down, but not the whole profession.”

Next, he says, the federal government extended the helping hand with its Paycheck Protection Program (PPP) loans. While a successful lifeline, unfortunately, some businesses—including dental practices—had trouble figuring out the intricacies of the program. Then, when practices re-opened, it was a mixed bag of fortune and opportunity.

“We had a reopening, which was the first time we’ve ever had that,” Dr Levin says. “Most practices opened in about a 4- to 6-week period throughout the country. Then we had pent up demand. We had enormous demand, because there was no underlying fundamental that hurt dentistry, other than the pandemic. For example, in a recession, you would lose a lot of patients, because they would be watching their financial capability. When practices reopened, patients were lined up and waiting to come in. Many were emergencies, many wanted to complete treatment.“

Then it was really interesting,” he continues. “People had increased discretionary spending, because they weren’t spending their money on travel and entertainment and restaurants, the way they had been. So, many practices also experienced patients who wanted to then have dental procedures completed that they have not opted for in the past.”

But then, after practices responded to that pent-up need, the pendulum swung back the other way—they saw a 5 to 10 percent drop off in demand in the fall.

It's unfortunate to say, but labs are used to business fluctuations because of crises. And, while the pandemic was different than any other calamity, labs have been able protect their operations in the event of future disasters.

“Dental laboratories that serve a regional or national client base are used to dips in production (mostly weather related – hurricanes, snow storms, fires, etc),” Napier observes. “However, these events, and their lasting impact, are usually shorter in nature than a pandemic. Dental laboratories have learned how to better manage workforce and production for longer shutdowns that may occur in the future.”

As a result of the pandemic, Napier expects the relationship between practice and lab to essentially evolve. First, he looks to infection control measures.

“It’s likely that intraoral scanning system sales will grow, as it allows dentists and labs to use digital impressions, as opposed to traditional impressions,” Napier says. “This mitigates some of the concerns on infection control, in terms of workflow.”

He also advises ensuring that practices partner with Certified Dental Laboratories.

“Dentists would be wise to look at dental laboratories that are a Certified Dental Laboratory, as they adhere to stringent OSHA standards related to infection control and hazard communication,” Napier says.

Additionally, for those doctors who start embracing chairside systems, labs can serve in a consultation capacity.

“Chairside services, whereby the dental laboratory technician is called upon to help with custom shades or complex cases [with a GP and/or oral surgeon], continue to grow in terms of demand,” Napier says. “It will not be uncommon for dental laboratories to seek their dental clients to sign off on mutual infection control/PPE protocols to protect all parties including dental patients.”

It’s no secret that computers have—and continue to—streamline dental practice operations. Adopting a solution with cloud computing at its core not only helps with day-to-day practice matters, but also helps crisis-proof operations.

“Cloud practice management is great for dental practices, because it provides flexibility and convenience to the dentist, the dental team, and their patients,” Dan Larsen, Principal Product Manager at Henry Schein One, says.

Cloud computing, simply put, means that the practice’s computational functions are performed and data is stored at an offsite data center, accessed via the internet. These dental practice management systems are useful for both single-site as well as multi-site practices.

“Single-site practices will benefit from how easy it is to learn, and appreciate the simplicity of having a single-cloud solution that includes the features they need, right out of the box,” Larsen says. “Multi-site practices appreciate the ease of scaling up new office locations, centralized management and control of the system, and a single patient record—when patients visit more than 1 of your locations, they have a single, consolidated patient record.”

Employing a practice management system with a decentralized infrastructure makes great sense, especially if there is a natural disaster like a fire or a flood. The utility and usefulness of cloud computing was proven during the unique challenges posed by the pandemic.

“We heard from a number of customers during the pandemic who were so happy they chose Dentrix Ascend as their cloud practice management software, because it allowed them to easily transition several of their team members to do administrative work from home without requiring any proprietary desktop software or setup,” Larsen observes.

Moving to a new system is daunting both from operational and expense points of view, and embracing a system that relies on the internet may conjure questions of reliability. But, Larsen says that systems and infrastructure are robust enough to support practices of all sizes and complexities.

“In many ways it reduces complexity,” he observes. “The dental team doesn’t need to worry about network connections to servers in the office and keeping all of their desktop products talking to each other. We’ve seen internet service providers continue to get faster, more reliable, and less expensive over time. With our Dentrix Ascend cloud imaging solution, we also offer an off-line mode, so if internet in the office does go out, you can still acquire x-ray images and they sync back to Dentrix Ascend automatically when connection resumes.”

Personal Protective Equipment (PPE) became the unanticipated star of the pandemic. While everyone knew its importance before, its necessity became even more clear.

“Different PPE is required for different situations in the practice,” Wilson observes. “The uses of PPE are not necessarily new to dentistry, but depending on the type of procedure, there are different levels of protection that they provide. For example, during an aerosol-generating procedure, what precautions do I need to take for that? So, we have the interim CDC guidance that definitely says you have to have an N95 respirator for any aerosol-generating procedures, but what COVID caught us off guard with was that you needed N95s to be a citizen, just to exist right now. That’s where it really put a strain on the supply chain.

It’s the same thing when it comes to environmental disinfection. There are different classifications. There’s critical, non-critical, and semi-critical. When you look at the different classifications of environmental disinfection, instrument reprocessing needs, PPE, and treatment needs, it’s making sure that we have the necessary items on hand to manage the different scenarios that may be presented, which is what we would see on an average day in clinical care.”

Although CDC and OSHA have PPE guidelines in place for dental professionals, Wilson notes that those are basic, everyday standards, but the times may dictate more protection.

“We have to make informed decisions and the information has been out there in terms of establishing the baseline,” she says. “And then the pandemic just adds another layer of contingency, but there’s guidance for the contingency. The dental industry is used to hearing from the CDC in terms of having guidance for patient safety. We always have gotten that from the CDC, but some industries aren’t used to really having the CDC on their radar, providing guidance for how they do things daily, like healthcare is.”

Throughout the pandemic, scarcity and PPE shortages plagued the profession. How should practices prepare so that they’re not caught off-guard in the future?

“I would encourage practices to accumulate 3 times the normal amount of PPE and keep it at that level,” Dr Levin says. “Now, I want to be clear: I’m not suggesting hoarding. Eventually, there’ll be as much PPE available as anyone wants to buy. And should we hit another pandemic-like issue, then you’re prepared and you’re not running out as quickly.”

Where to find that PPE is another important factor. In an effort to secure adequate amounts of PPE, practices may have found themselves making poor decisions.

“We’ve learned some hard lessons, where we were trying to get whatever patient treatment supplies we could from wherever we could,” Wilson says. “And some people had the unfortunate lesson of learning that not all PPE is created equally. There are regulatory approvals in place for a reason: to give us that stamp of approval, that this is going to give us the protection that we need for both the patient and the provider.”

While dental practices are, first, in the business of caring for patients. That being said, they are still businesses, and in order to be successful, they need money. But they don’t just need money to be successful, they need it to stay afloat, especially in times of crisis.

“Businesses with cash always survive and typically do well,” Dr Levin observes. “The data showed that when the pandemic hit, over 90 percent of practices had less than 1 month of cash. We are encouraging practices to carry 4 months of cash in a reserve account. And, if the cash is never needed for a crisis or a pandemic, it becomes income. And the answer to, ‘How do we accumulate that?’ is ‘slowly’. You don’t need to have it overnight, but build it up over a period of time.”

During the pandemic, practices that did not have such levels of savings we were able to accept a helping hand from the government in the form of Paycheck Protection Program (PPP) loans. Dr Levin says those loans were practice-savers.

“Had the government not come out with the PPP and other loans, we would have lost more practices,” he observes. “And, I am delighted that the government stepped in and helped practices in two ways: Number one, many practices terminated their staff, so the staff could get unemployment benefits, and there was a big kicker on unemployment, much bigger than you would normally get. Number two is next time around, there may be no excess unemployment and there may be no PPP loans, and you don’t want to wait until there’s a crisis to see if that happens. If it doesn’t happen, practices could lose a lot of the practice or all of the practice. So, that’s the other factor is keep in mind. This is the first time we have ever seen a dental practice bailout, which was part of a national stimulus package. Next time, it could be a stock market crisis—or whatever the case may be—and there might be no stimulus, leaving a lot of practices in serious trouble. So, another reason to maintain 4 months of cash is so you have your own stimulus, in the event that you need it.”

Staffing is also a concern when a crisis arises. The practice may find itself short-handed, so it is necessary to ensure that critical practice functions are covered.

“Many practices had staff members that did not return, or that returned but did not stay, which left them with certain job skills that were not available within the practice,” Dr Levin says. “Cross training the staff on critical functions is important. You want people who know how to do a job, or if you lose one person, you’re really hurting the practice. The doctor may be staying at night and weekends trying to do the work.”

He also recommends ensuring that patients know what is going on with the practice in times of trouble.

“Have an ongoing communications program with patients,” Dr Levin says. “The Levin Group encourages dentists to have communication with the entire patient base every 30 days. Many good businesses are doing this. And then that communications program, which can be, in good times, about the practice, dentistry technology, new services. But if a crisis comes up, you already have a platform for a crisis communications program. We worked very hard during the pandemic, with the entire profession, to give them materials to send out to their patients so that patients would come back and felt safe. They were hearing regularly from their dentist, getting updates almost on a weekly basis on the status of the practice and when they thought they might reopen.”

Ultimately, Dr Levin observes that successful practices—whether in times of trouble or not—rely on the practices leadership for success.

“Be a good leader,” Dr Levin advises. “A good leader has a couple of key qualities. Number one, they’re compassionate. As most Americans, they’ve got anxiety, they have illness, they have elderly parents, they have kids that were out of school, and compassionate leadership was critically important.

“The second factor is humility,” he continues. “A good leader maintains humility rather than feeling like, ‘Well, I’m successful.’ When you start to feel successful, that’s when you’re in trouble. The top 3 things that a great leader does in a crisis is communicate, communicate, and communicate. Keep the team informed, tell them what’s really going on. Let them know what you don’t know, give them optimism, which is hope for a better future. Make the workplace a safe zone where they feel like they have a purpose and they’re contributing.”

Who knows when (or what) the next pandemic will be. There may not be another one for another 100 years; or it may happen next month. The important thing is to be prepared.