Kick in the Teeth: How COVID-19 is hitting the local dental community

(Pictured top l-r: Rathke, Madion, Bergsma. Bottom: Crouch)

In March, Michigan Governor Gretchen Whitmer issued an executive order requiring all “non-essential medical and dental procedures” to cease. Prior to that, the Michigan Dental Association (MDA) had issued recommendations for dental professionals throughout the state to close their offices for at least two weeks. The goal was to slow the spread of COVID-19 and help “flatten the curve” of infections that could otherwise overwhelm the healthcare system.

However, according to several local dental professionals, the closures have been executed in such a way that they’ve sent more patients running to emergency rooms.

Dan Madion is an oral surgeon and a partner at Grand Traverse Oral Surgery (GTOS). He’s also one of the few dental professionals in town still working regularly, thanks to the fact that oral surgeons are generally considered first responders in dental care.

Many of the things that Madion and his partners treat – emergency dental extractions, infections from dental abscesses, facial trauma from car accidents – tend to qualify as emergent and essential procedures. GTOS is also on call through Munson Medical Center, which means any patient who comes to the emergency room seeking help with something oral surgery-related ends up getting treated by Madion or one of his colleagues. In some cases, those surgeries are inpatient, rather than at the GTOS offices. Since dental practices started shutting down in early May, Madion says he’s been worried that more patients will end up in the ER without true emergency status.

“…(R)ight now, a lot of our cases are coming from hospital emergency rooms,” he said. “Patients will go in with bad toothaches or something like that, and we’ll get called and will try to direct the patients quickly to our office to keep them out of the hospital.”

Madion says that the initial call by the MDA to close dental offices has led to confusion. “When the MDA first called for all dentists to close their offices, that was problematic, because the dentist is the true first line of treatment,” he said. “As oral surgeons, we depend on the dentists to direct patients our way if they need surgery.”

Brian Rathke, a dentist with practices in Bellaire and Elk Rapids, says he has been trying to keep the lines of communication with his patients open to ensure that he is treating urgent or emergency cases rather than letting those patients head to the ER.

“When a patient goes to the ER instead of going to a dental office, they’re taking resources away from those frontline providers,” Rathke said. “They’re taking up space, they’re taking up a bed, they’re taking up a doctor, they’re taking up PPE.”

Rathke says he thinks the best thing to do is for dentists to see their essential care patients to keep them out of the ER. “Otherwise, our oral surgeons aren’t getting the proper triage of patients,” he said.

The proper triage system includes assessing, diagnosing and then referring a patient to an oral surgeon or orthodontist if necessary, Rathke said. “That’s kind of our triage system,” he said. “And when all of the offices are shut down, it interrupts the steps of triage that the oral surgeons count on.”

To keep assisting patients during COVID-19 – keeping them away from the hospital – local dental professionals are ratcheting up their teledentistry offerings. Rathke uses a cloud-based system that allows him to access full patient charts remotely from any device with an internet connection.

It’s not just dentists, either: Spencer Crouch, a local orthodontist who owns Traverse City’s Up North Orthodontics – is in the process of rolling out video-chat appointments for his patients.
Figuring out ways to treat patients without violating Michigan’s stay-at-home order is only one of the challenges that the several hundred northern Michigan dental professionals are contending with right now. Another hurdle is the one that virtually all small business owners are facing in the age of COVID-19: how to keep the lights on and the staff employed with little or no money coming in.

The financial blow has been particularly tough for Crouch, who is the youngest orthodontist in northern Michigan. A 2008 graduate of Traverse City West Senior High, Crouch found his way back to the area last spring after finishing University of Michigan’s Graduate Orthodontic Program. He still had student loans, his wife had just given birth to their first child and he was preparing to purchase and take over three separate offices owned by Dr. Bill Northway and Dr. Bob Portenga, both of whom are retiring. After spending the summer working with Northway and Portenga and meeting their patients, Crouch took over full operations in September.

Then COVID-19 hit. “Within six months of flying solo without the older doctors, this all happened, which is pretty wild,” Crouch said. “Luckily, at this point, we’ve met all the patients and gotten issues like merging the computer software out of the way.”

The timing has impacted the practice, he said. “We were at a pretty steady point of being able to grow the practice and get into a solid groove, and then this hit,” he said. “So, this would have impacted the practice more if it happened last fall, but it’s definitely not fun to have it happen within your first year. I wouldn’t recommend it for other people going through opening practices or businesses.”

Crouch initially had to furlough his team, which includes six other full-time employees. “As a young business, we can’t fully support a whole payroll plus other business expenses for an indefinite period of time,” he said. “There would come a point where that just doesn’t work and we’d go under.”

Relief from the Coronavirus Aid, Relief, and Economic Security Act (CARES) has since helped clarify a path forward, for everything from re-hiring staff (and covering payroll expenses) to paying key business operating expenses.

Even with the CARES Act loans – which are set up with built-in loan forgiveness protocols – Crouch isn’t sure what life after COVID-19 will look like for his fledgling practice. When the MDA recommended dental offices take a two-week break, Crouch and his team went to work contacting patients and rescheduling appointments. When the stay-at-home order from Governor Whitmer came through – and then got extended – all the rescheduled appointments had to be rescheduled again. Now, Crouch says he’s waiting for the “moving target” of the stay-at-home order to stop moving before he makes any concrete plans for in-office visits.

Sara Bergsma, a long-time Traverse City orthodontist, is facing similar logistical hurdles. So far, Bergsma and her team have had to push out more than 400 patient appointments indefinitely. She’s already planning ahead for when her practice can reopen, but says that the process is complicated given that the COVID-19 recovery process will likely be gradual.

“Our schedule when we come back is not going to look like our old schedule did,” Bergsma said. “A lot of times, we’d have eight to 10 patients in the building, and then of course their families, and it was sort of standing room only.”

Changes will include spreading patients out physically and time-wise, she said.

“Now, I think we’re going to be looking at spreading the patients out into the various different spaces we have in the clinic, so there is eight to 10 in between each patient or they’re in entirely separate rooms,” she said. “That’s a big challenge because of the number of different types of procedures that we have. It’s kind of like this big jigsaw puzzle that I’m working on.”

Some treatments, Bergsma adds, require special pieces of equipment, which means they can only happen in certain parts of the facility. Other types of treatments need to occur more times in a day than others. And not every treatment takes the same amount of time. All these factors make scheduling a slate of patients harder than simply picking out time slots and making sure everyone is a certain number of feet apart.

The sheer backlog is a problem, too. Bergsma says that she and her team will likely reschedule all patients for appointment times at random, rather than try to call each patient individually to coordinate schedules. Patients who can’t make their scheduled appointment times will be able to call and schedule different times, but the Bergsma says the approach will save the Bergsma Orthodontics team days (if not weeks) of phone calls, follow-ups and schedule negotiation.

Crouch, meanwhile, says he’ll mostly try to reschedule appointments in the order that they had to be canceled in the first place. A top priority, he says, is making sure kids who should have gotten their braces off weeks ago have the opportunity to do so as soon as possible.

“For the ones who were just about to be done with treatment, the delay definitely stinks,” Crouch said. “Getting your braces off is a big moment, and not having that is similar to those seniors in high school or college who won’t be able to celebrate graduations. It’s just another thing to add to the list.”

Of course, while dental professionals are looking ahead to the day when their practices can open again, there’s also the possibility that Governor Whitmer’s stay-at-home order gets extended and keeps non-essential businesses closed indefinitely. There are contingencies for that outcome, ranging from the aforementioned teledentistry technologies to curbside deliveries of Invisalign aligners and retainers.

At some point, Bergsma thinks that what the state currently considers to be non-essential dentistry – essentially, anything not involving bleeding, breathing impairment, broken bones, or significant pain – will need to be re-assessed and re-labeled.

“The vast majority of orthodontic patients can miss one appointment and not have any bad consequences,” Bergsma said. “It’s when we get to a point where several appointments are missed or a longer span of time goes by that this becomes a real problem for the patients. We can say that these closures are okay for a bit, but with orthodontics, we are putting forces on teeth and we need to check in and make sure that they’re doing what they’re supposed to be doing. So, I think in the not-too-distant future, the state would need to loosen some of these guidelines. At least I hope they would.”