Hours into the search and it was little progress made other than to find disposable gowns at a thousand-percent mark-up.

Such is the recent story for many dental professionals in Minnesota who were given the go-ahead to start reopening as early last Monday. Gov. Tim Walz gave the go-ahead for dental offices to reopen May 11 after they’ve been closed for nearly two months to all but emergent care, but that change in direction proved an abrupt one as PPE remains scarce and a thicket of new operating policies are required.

Spring Park Dentistry’s Dr. Kyle Danielson said there was one day when he spent four hours searching for the gowns and N95 masks that will be required of him and other dentists, dental assistants and hygienists under the guidelines drawn up by the Minnesota Board of Dentistry.

“It’s been almost impossible,” he said of getting the PPE. The two suppliers he normally does business with aren’t stocked for the demand, and he’s had to look elsewhere, saying also that costs are adding up: a gown that normally would cost him 30-40 cents is retailing at $4-$5 now.

Danielson said he’s planning on a slow reopen, operating just three days a week and bringing back just two of his four staff while prioritizing those 20-some patients who have called in the interim with broken fillings or chipped teeth—the emergencies that weren’t emergent enough under the previous government order. Since the order came down to end elective care, Danielson had been averaging just one patient a week, down from the 12-14 he’d usually see.

Just 1.5 miles west, a similar hunt for PPE was underway as Dr. Stephanie Miner of West Lakes Dentistry in Mound was meeting with the same dearth of supplies, especially the N95 mask.

“It’s kind of a fallacy that they’re readily available because they’re not,” she said. “There’s still kind of a ration of supplies that we might need that we’re trying to be really judicious about it and making sure that we’re scheduling appropriately so we have what we need to protect everybody.”

Dentists around the state are largely adhering to guidelines drawn up by the Minnesota Board of Dentistry. MBD issued a notice May 7 with details on required PPE and recommended clinic protocols, asking also that clinics submit facility plans outlining the procedures that will be available and how aerosols and contact will be limited.

“The Governor’s announcement was not a GREEN LIGHT to open the flood gates,” the notice reads, cautioning that “Prioritization of care is still REQUIRED as well and based on the needs in certain clinical situations.”

The continued emphasis on social distancing, even as these doctors work directly in the mouth, will likely show up in reduced hours and limited staffing; waiting rooms may be bypassed altogether as clinics adopt policies like the “text-to-chair” practice that Miner has used for her patients over the past month and a half: drive up, text on arrival and be ushered into the chair when the doctor is ready to seen them.

Three Hepa air filters will fan out the rooms at Spring Park Dentistry, cleaning the air within about 20 minutes after every patient. A peroxide rinse will also be required, said Danielson. Both Danielson and Miner said that extraoral suction and dental dams to mitigate the spray-like mist of aerosols will be in heavy use.

Patient screening questionnaires and taking patient temperatures, as Miner intends to do at West Lakes, could also be part of the new normal at many clinics. Teledentistry, patient surveys or phone check-ins to determine just how long an appointment can wait are also part of that mix.

“I opened my Mound practice from scratch, and in some ways I feel like we’re reopening from scratch just because of the number of policies and procedures and equipment almost that we’re having to do things differently,” said Miner.

Not everything has been a challenge, though; and some of it has even been fun: Miner said 3D printing of custom-fit face shields—not just a visor but a visor that fits over goggle-like magnifying eye loupes—are now being made. “There are different industries that are changing gears, trying to be helpful and find that niche of things that are needed right now.”

On the radar, too, is the question of insurance. The American Dental Association is asking providers to help cover costs of PPE by allowing clinics to bill out for it, urging in an April 21 statement that “Third-party benefit programs should either adjust the maximum allowable fees for all procedures or allow a standard fee per date of service per patient to accommodate the rising costs of PPE.”

But not all insurers are on board with that recommendation, and that could mean having to cut accepted plans or transferring costs to patients.

“It’ll be interesting to see how the insurance game changes. I just think they have to step up and kind of make up for some of this if they want to stay in business,” said Danielson, who said he’s seen some clinics drop plans already.

“I’m hoping that a lot of people don’t have to delay if they need treatment because unfortunately a lot of times dental insurance does not even really cover it, or doesn’t cover it like medical insurance does, so people often do have out of pocket costs,” said Miner, who estimated that the cost for just a routine cleaning could increase by as much as 10 percent if insurance doesn’t adopt the ADA recommendation.

Neither Danielson nor Miner said they intend to cut plans yet, but Danielson said it could just be too early to tell, adding that in March, just prior to closing, he was about to sign off on adding other providers but, with an eye on how things had been progressing, held off on that.

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