Additional fees for PPE

As dental clinics are re-opening for routine care across the country, there has been discussion within the dental community how to deal with the additional costs associated with operating in compliance with current infection control guidelines. In order to treat patients, many dentists have been subject to additional expenses such as: implementing building modifications, procuring medical-grade ventilation equipment, compensating staff for added responsibilities, sourcing and purchasing personal protective equipment (PPE). Less obviously, the additional COVID precautions requires more time between patients to properly prepare a room for treatment and to clean-up afterwards and often makes procedures more time-consuming, which represents less income-generating potential.

Many types of PPE, such as masks and respirators, gloves, gowns, shoe covers, and patient drapes, are single-use disposable items and represent a discrete cost directly associated with each patient visit. Currently, some PPE is in short supply and has thus resulted in higher prices. For example, a disposable gown may cost more than $5 each. This has prompted the creation of two new fee codes: (1) 99901 for PPE required for non-aerosol generating procedures (such as exams), and (2) 99902 for PPE required for aerosol generating procedures (such as most restorations and surgical extractions).

The Canadian Dental Association (CDA) manages a Uniform System of Coding and List of Services (USC&LS), which provides a standard system for dentists across Canada to document their services and prepare claim forms to insurance carriers. Provincial dental associations use the USC&LS to publish a suggested fee guide which is reviewed regularly. It is important to emphasize that provincial fee guides are suggestions only, as dentists are free to charge for their services whatever they deem reasonable. In BC for example, the British Columbia Dental Association (BCDA) suggests $10 for both 99901 and 99902.

The new existence of fee codes does not necessarily mean that the cost is being reimbursed by insurance carriers. These codes are still under review by many carriers. Until your carrier decides makes a decision about coverage, this additional cost will be an out-of-pocket expense for the patient.

Image from : Main Street Dental Group in Venture, California

https://www.dentistrytoday.com/news/todays-dental-news/item/6223-inspiring-dentists-provide-emergency-care-during-the-covid-19-crisis

© The Straight Tooth 2020

Non-medical masks and face coverings

The following has been copied from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks/about-non-medical-masks-face-coverings.html

Wearing a homemade non-medical mask/facial covering in the community is recommended for periods of time when it is not possible to consistently maintain a 2-metre physical distance from others, particularly in crowded public settings, such as:

• stores
• shopping areas
• public transportation

Public health officials will make recommendations based on a number of factors, including the rates of infection and/or transmission in the community. Recommendations may vary from location to location.

Wearing a mask alone will not prevent the spread of COVID-19. You must consistently and strictly adhere to good hygiene and public health measures, including frequent hand washing and physical (social) distancing.

Appropriate use of non-medical mask or face covering

When worn properly, a person wearing a non-medical mask or face covering can reduce the spread of his or her own infectious respiratory droplets.

Non-medical face masks or face coverings should:

• allow for easy breathing
• fit securely to the head with ties or ear loops
• maintain their shape after washing and drying
• be changed as soon as possible if damp or dirty
• be comfortable and not require frequent adjustment
• be made of at least 2 layers of tightly woven material fabric (such as cotton or linen)
• be large enough to completely and comfortably cover the nose and mouth without gaping

Some masks also include a pocket to accommodate a paper towel or disposable coffee filter, for increased benefit.

Non-medical masks or face coverings should:

• not be shared with others
• not impair vision or interfere with tasks
• not be placed on children under the age of 2 years
• not be made of plastic or other non-breathable materials
• not be secured with tape or other inappropriate materials
• not be made exclusively of materials that easily fall apart, such as tissues
• not be placed on anyone unable to remove them without assistance or anyone who has trouble breathing

Limitations

Homemade masks are not medical devices and are not regulated like medical masks and respirators:

• they have not been tested to recognized standards
• the fabrics are not the same as used in surgical masks or respirators
• the edges are not designed to form a seal around the nose and mouth

These types of masks may not be effective in blocking virus particles that may be transmitted by coughing, sneezing or certain medical procedures. They do not provide complete protection from virus particles because of a potential loose fit and the materials used.

Some commercially available masks have exhalation valves that make the mask more breathable for the person wearing it, but these valves also allow infectious respiratory droplets to spread outside the mask.

Masks with exhalation valves are not recommended, because they don’t protect others from COVID-19 and don’t limit the spread of the virus.

Medical masks, including surgical, medical procedure face masks and respirators (like N95 masks), must be kept for health care workers and others providing direct care to COVID-19 patients.

Image from: https://www.todayville.com/edmonton/to-or-not-to-wear-a-homemade-mask-that-is-the-question/

© The Straight Tooth 2020

Response: My child’s anterior crossbite

This is the right time to address anterior crossbite. Annabelle currently has mixed (primary and permanent) dentition. As her permanent teeth come in, this is the ideal time to intercept spacing/malalignment issues because of the leeway space due to the difference in size between the primary and permanent tooth that comes in. Normally primary teeth are slightly spaced, so Annabelle’s slightly crowded teeth should be monitored by an orthodontist (which is what you are doing).
Good reference on leeway space : http://orthonj.com/leeway.html

Children are remarkably adaptable, so I think that it’s likely that Annabelle may in part be slightly posturing her jaw forward slightly so that her teeth fit together, i.e. a functional anterior crossbite, although a dental exam would be needed to determine this with greater certainty. With the anterior crossbite, her teeth can only bite together a certain way – correct the crossbite and her upper to lower jaw relation will likely spontaneously improve. It is also possible that a “protruding lower jaw” may indicate a skeletal discrepancy. To keep this discussion basic, let’s assume that Annabelle’s crossbite is her only issue.

In general, there are different approaches an orthodontist can take to address a problem and it depends on what they feel most comfortable doing. She is recommending either: (a) fixed appliance (i.e. the limited braces option); (b) removable appliance, which are the two broad categories. 

The terminology you mentioned is not technically correct – a “retainer” serves to keep everything in the proper place (root word retain), not to move teeth into the desired position. Although many dentists may (Your thought is correct about wearing a retainer following orthodontic treatment for the rest of the patient’s life, or for a good number of years at least). So the proper term in this situation is not “retainer”, rather “removable appliance”.

The textbook solution to a simple anterior crossbite is a finger spring removable appliance with posterior bite plane. Other possible approaches include a similar appliance with a screw instead of a finger spring, or an inclined bite plane alone.

The orthodontist might be recommending the fixed appliance option because she can do it “in-house”, i.e. it costs her only her own time and a few materials, whereas the removable appliance needs to be sent to a dental lab and so there will be a lab fee involved (the cost of which is usually passed along to the patient). But a simple finger spring appliance is not expensive, I would guess maybe $175 to 200.

Maybe the orthodontist has other factors in mind that I don’t know about. Otherwise, considering just this information, I would go with a removable appliance because Annabelle can take it out to brush and floss her teeth. She’s a good kid, so I would think that she is reasonably responsible to not lose it. Braces would make dental care more difficult and increases Annabelle’s risk of cavities. Annabelle is a little young to be trying to take care of her teeth in braces, so this route could be challenging.

I would recommend looking around and getting a free consult from another orthodontist and see if you like what they say and what prices they quote you. 

Another suggestion: until Annabelle starts her treatment, you can ask her to put finger pressure on her bottom tooth that sticks out whenever she thinks about it. Orthodontic movement is best achieved by light continuous force.

Image (above) of appliances from: https://www.dentistrytoday.com/orthodontics/1563–sp-133686282

Image (below) of lower inclined bite plane with before and after pics from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169927/pdf/DENTISTRY2011-298931.pdf

© The Straight Tooth 2020

Question: My child’s anterior crossbite

Annabelle’s front top tooth is coming out in crossbite, and is slightly behind the bottom tooth, so her dentist referred her to an orthodontist. The orthodontist took x-rays and did exam. She thinks her teeth are slightly crowded and the lower jaw protrudes forward a little bit, but she’s not  overly concerned yet (since jaw will continue growing until around 9/10 years old; she’s 7 now).  However as the front top tooth grows, she thinks it will start impinging more on the bottom teeth, which could cause more complications (teeth chipping, cause misalignment of other teeth, putting forward pressure on lower jaw).

Her plan was to add ~4 braces to the top to pull/twist the single front top tooth forward until it’s in front of the bottom teeth; from there she’ll remove the braces and the tooth should “self-retain” itself as it grows out (at least it should stay in front of the bottom teeth; whether it will stay straight or how it will align in relation to the other teeth is another question). Since it’s a relatively minor adjustment, the braces may only be needed for a few months.  Her second suggestion is a retainer; however this would be more expensive, take more time (need to do molds, send away to manufacture, etc.), and kind of a waste since it wouldn’t be needed anymore in a few months.

Basically, do you think it’s wise to proceed with this procedure now, or is she too young and should wait until a bit older? Also we’ve heard you need to wear retainer for rest of life after braces; but this is not the case here, correct? 

© The Straight Tooth 2020

Why isn’t my dentist open yet?

In BC, a “Restart Plan” exists. Dental offices are permitted to open with enhanced protocols as of the start of Phase 2, which was May 18, 2020. Similarly across Canada, based on their provincial plans, the public may be expecting their dental office to now be open or to be opening soon.

So why isn’t my dentist open? Most dental clinics are operated by the dentist-owner as a small business. Before reopening, dentists have an enormous number of requirements to satisfy in order to ensure the health and safety not only of all patients, but also staff and any third parties visiting the premises.

Requirements are specified by several authorities and have been developed, issued and revised as the COVID-19 situation has progressed. These requirements do not always correspond to each other and sometimes clarification is required to apply to a specific dental workplace. In BC, the relevant authorities include:

• BC Centre for Disease Control (BCCDC)
• Ministry of Health and the office of the Public Health Officer (PHO)
• WorkSafe BC
• The College of Dental Surgeons of BC (CDSBC)

A responsible dentist-owner needs to navigate and satisfy these requirements plus deal with COVID-10 complications related to staffing, supply procurement, rent payments, etc. Needless to say, the situation is complex and your dentist may not be ready to re-open safely.

My advice to patients:

• If you feel you have an emergency or urgent concern, do not wait to contact your dentist! Your dentist should be able to provide emergency care or at least refer you to someone who can.
• If you are waiting for routine, preventive or elective care, please be patient. Monitor your dentist’s website to watch for announcements. Many dental offices are currently answering their phone and you will be able to ask a staff member your questions.
• Continue to take care of your teeth at home. See a previous post about Preventing Dental Emergencies.

© The Straight Tooth 2020

COVID-19 – Clarification on Aerosols

My post, “COVID-19: The Connections Between the Dots,” specified that, based on known evidence according to the CDC (Centers for Disease Control and Prevention), the primary modes of transmission between humans is through droplet spread and contact.

Aerosols are smaller particles than droplets and, unlike droplets, can remain suspended in the air for long periods of time. Airborne transmission, i.e. through aerosols, has not been identified as a primary mode of transmission. It seems that infected humans do not tend to generate aerosols during normal activities.

That being said, airborne transmission is a notable risk in specific medical procedures involving an infected patient, for example, during endotracheal intubation and non-invasive positive-pressure ventilation. Also many dental procedures, such as those requiring the use of a high-speed handpiece (dental drill), can potentially generate aerosols of a patient’s saliva.

Reference: https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations

Image from: http://dmndl.blogspot.com/2011_10_01_archive.html

© The Straight Tooth 2020

How to Avoid Having a Dental Emergency During COVID-19

Did you know…

There are many measures within your control to prevent dental emergencies and having to see a dentist, whether during a pandemic or normal times.

Helpful hints…

• Maintain a healthy oral home care routine. Typically this includes:
  • Brushing your teeth twice a day, in the morning and prior to going to bed, for two minutes at a time. Flossing daily.
  • If you have a removable appliance, remove it every night and clean it thoroughly.
• Comply with any special instructions your dentist or specialist has previously provided.
• Recognize if you have developed an unhealthy diet while self-isolating or working from home. Limiting frequency typically has a greater impact than amount.
  • Frequent snacking on sugars and other fermentable carbohydrates increases your risk of cavities.
  • Constant sipping on wine, lemon water, carbonated drinks (regular or diet) or other acidic foods leads to acid erosion.
• If dental decay tends to be a fairly frequent problem for you, ensure you are receiving some daily exposure to topical fluoride, which helps strengthen your enamel and prevent cavities. Fluoride is a complex topic, so I will write a separate post with more detail.
• Chewing gum or mints sweetened by xylitol can also aid against dental decay and also dry mouth.
• A pandemic is perhaps not the best time to try new sports or engage in risky physical activities. Still to a comfortable workout routine. Consider wearing a sports mouthguard when weightlifting or playing sports that may lead to head or facial trauma.
• Stress can cause muscle tension and jaw pain which could feel like a toothache or headache. Outdoor walks, stretching, and quiet time for yourself can help you manage your stress levels. Temporomandibular disorders is a complex topic, so I will write a separate post with more detail.
• Take a look in your own mouth once in a while and get accustomed to how it looks normally. You are in the best position to be able to observe any early change. Catching a problem early can also help avoid a later emergency.

© The Straight Tooth 2020

Dental Clinics Re-Opening: What to Expect

Across Canada, dental clinics are beginning to re-open. Here in BC, the Premier recently announced that greater access to dental care, with “enhanced protocols” will occur with Phase 2 of BC’s Restart Plan to begin on May 19.

It is best to be prepared for an abundant use of caution and PPE. Here are examples of some changes you may find at your next dental encounter:

• Your clinic may have beefed-up their online and social media presence, perhaps now with the ability to book your own appointment online.
• Administrative aspects, such as completing forms, asking about insurance claims, and paying your invoice may be completed online or over the phone rather than in person.
• You may be asked questions to screen you for COVID-19 symptoms immediately prior to your appointment.
• You may be asked to wait in your vehicle when you arrive for your appointment, and someone will call your mobile number when it’s time to go straight in to the dental chair.
• You may be asked to put on a mask and use alcohol hand sanitizer upon entering.
• If the waiting room is open, seating is spaced-out and there may be no reading material.
• The reception counter may have a plexiglass screen.
• All clinic personnel may be wearing masks.
• If you are receiving a consult or exam, the dentist may be wearing minimal PPE.
• If you are receiving more extensive treatment, you may be asked to wear a protective bonnet and/or gown. The dentist may enter the dental operatory already dressed in extensive PPE perhaps including: scrub cap, protective eyewear and/or faceshield, surgical respiratory, gown and shoe covers.
• There may be a portable air filtration unit in the room. When your chair is reclined, a large nozzle will be positioned near your chin to suck up and filter the air.
• At the end, payment may preferred by card (no cash).

Left image – This fantastic image is from: https://www.barrietoday.com/coronavirus-covid-19-local-news/area-dentists-aching-to-sink-their-teeth-back-into-work-2336545, contributed by Dr. Jerry Collins of West Ridge Family Dentistry.

Right image – Portable air filtration unit, from: https://www.air-quality-eng.com

 

© The Straight Tooth 2020

How to Wash your Hands

This procedure ensures that you reach all the surfaces of your hands. When using alcohol-based hand sanitizer, dispense a dollop the size of a loonie, rub all surfaces as if washing your hands, and keep rubbing until dry.

Image from: https://www.buzzfeed.com/terripous/how-to-wash-hands-properly-according-to-science

How to Correctly Wear a Mask

Remember that a mask cannot prevent infection. Wearing a mask incorrectly may provide a false sense of security and actually result in an increased risk.

Key points:

• Wash/disinfect your hands before starting.
• Ensure the mask is the right side out. The material on either side have different characteristics.
• Form-fit the mask to fit snuggly around the nose.
• Pull the mask down to fit snugly over your chin.
• When removing your mask, assume that the outside surface is contaminated.
• Wash/disinfect your hands after removing your mask.
• Disposible masks are not intended to be re-used.

 

© The Straight Tooth 2020