04 Jun Everything Dental Blog – Thoughts about Preparation and Re-entry for Dentists

By Jack Abrams

These ideas are exclusively mine and do not reflect Henry Schein or any other company.

While I no longer work in the field, I still maintain a strong connection to the streets. I speak with four or more dental offices daily. Lately, our conversations are about the arduous re-entry to work after a long hiatus in the war against Covid-19. A few of my dearest friends (old clients) asked me to share my personal recommendations regarding practice re-entry. So here it is.

Many dentists are frustrated with organized dentistry, the government, regulatory bodies and the supply channel. They feel disrespected and unappreciated because of the limited work regulations and guidelines thrusted upon the profession during Covid-19. The underlying and perhaps the most concerning fact is that dentists and dentistry were not perceived as vital contributing members of the medical community during the pandemic. For too long, the Oral Systemic Link has been validated but insurance companies, the medical community and legislators have failed to adjust policy or incorporate dentistry’s progressive, preventive approach to patient care. 

For almost three months we have been on the receiving end of advice and instruction. We’ve been told to quarantine at home, practice social distancing and avoid touching surfaces and even our own face. Although there is still a cloud of uncertainty regarding the virus, it is time for dental teams to strategize, prepare and get busy. Depending upon your location, you may have already opened your doors for business!

There is no time to waste

As you navigate practice re-entry, please be cognizant of the top four reasons why people delay making critical decisions. These are not ordinary times, you must act swiftly to reestablish your business while embracing a growth mindset.

1. Fear – Fear of Failure or Fear of the Unknown. Walter Hailey said “Fear is false evidence appearing real”.
2. Perfection – This is a major issue for Dentists because they tend to be perfectionists. It is a combination of their training and artistry. Years ago, the business and economics were more forgiving. Today, we should rely on technology and analytics to guide us and we build and improve as we go.
3. Energy – Every project requires a certain degree of passion to overcome our tendency to delay. Passion is the fuel for the engine of energy. It removes internal barriers and external distractions.
4. Focus – Focus is the key to success and a winning attitude. Focus allows us to prioritize and provide the resources congruent to the task.

Below is a long list of Back to Work bullets with some commentary. Please review the list in its entirety. I am confident that even the best prepared, will find a pearl among these bullets! *Remember – these ideas and recommendations do not reflect Henry Schein or any other person or company. These thoughts and this commentary are exclusively mine.

PREPARATION (This is a great time for reinvention):

• Use video conferencing to communicate with your team while you shelter in place and for conducting virtual training meetings in the future
• Connect with furloughed employees and show them you care. Share information about when the office will reopen and when they can expect to return to work
• Discuss re-entry and new infection control protocols with each team member, Discuss their role and responsibilities
• Invest in air purification equipment as new guidelines will likely impose regulation on aerosol spray and contaminants in the office air 
• Train team members on the proper use, maintenance, and record keeping for air purification equipment and other regulatory mandates 
• Work on new scheduling guidelines
• Discuss, develop and incorporate new customer service protocols to ensure a safe, comfortable and friendly customer experience
• Update your website, on hold answering service, patient engagement tools and social media content with your Post-Covid instructions and guidelines
• Reconfigure the waiting room to accommodate antipathetic patients with  proper spacing 
• Consider a Plexiglas partition if you have an open reception/greeting area
• Update all patient contact information as patients come in for appointments. Many offices could not communicate with patients because they had old cell phone numbers and emails
• Be flexible with key employees. Remember, schools are closed making it harder for single parents. *Speak with those valuable team members and develop a mutually beneficial plan 
• Speak with your accountant and financial planner often. Develop a budget to account for capital equipment and increased PPE costs and adjust your retirement planning accordingly. Be sure to take advantage of all government subsidies and/or forgiveness programs and strategize the best use of the section 179 deduction for 2020.
• Be prepared for difficult and highly educated patients who have complained about BPA, Methyl Methacrylate, Nut allergies and fluoride use in the past. These same valued patients will scrutinize your cleanliness and infection control measures.
• Build up your inventory of PPE.  Some products may be rationed for a while so be sure to stay on top of ordering. *Dealer inventories get depleted quickly due to unprecedented demand and hording

Facility:

• Invest in a patient PPE kiosk. These are usually stocked with masks, gloves and hand sanitizer for your patients as they enter the facility
• Consider a second waiting room (remove an operatory and make a second waiting room). This will give you a waiting room for hygiene and operative patients. By managing waiting room crowding you will improve patient flow and production numbers.
• Doors on rooms. Consider closing the treatment room doors for privacy and to accommodate high risk patients and patients with pre-existing conditions. This will aid in managing the proverbial aerosol cloud  
• Implement new – flexible hours. It’s no secret that 7:30am – 10 am is busy but the schedule is quieter from10 -12noon. We know the business quiets down after the lunch time and picks up after 2:30PM and remains busy until closing.
• Hire a professional cleaning service or investigate the options your dental dealer recommends to ensure and certify a safe and virus free environment 
• Post signs around the office about your enhanced Covid disinfection regimen 
• Discuss handpiece management and the sterilization process with your auxiliaries. Make sure you have enough HP’s and that you’re doing everything right according to the CDC guidelines and manufacturer recommendations. There will be great scrutiny about the spray that is generated from handpieces and scaler machines. This may be the perfect time to invest in a second sterilizer.
• Think about your offices location. Consider things like; how long will I be practicing? When is my lease up for negotiation? Would a retail or more visible location attract more patients and provide more patient parking? Would a larger facility allow me to add an associate or hygienist or a specialist(s)? Remember, 5-7+ operatories will attract more buyers when it’s time to sell!
• Eliminate magazine racks, literature holders, children games and patient beverage stations from the patient waiting room
• Deliveries: Instruct all labs, USPS, UPS, FedEx etc. to use your shipment/mail receptacle located outside or in the rear of the building. You do not want uninvited visitors. They crowd the space, make nervous patients anxious and interrupt workflow.
• Use signage to direct patient flow through the office and to create safe zones when entering and exiting the practice.
• Use tele dentistry in lieu of regular phone calls when it serves an advantage. Use the TD conferencing feature for peer and specialist collaboration. Learn to use Tele Dentistry like a pro. TD is a competitive advantage. 
• Equipment Service. Schedule summer and winter preventive service calls. Check your utilities (compressor, vacuum) and all operatory equipment (lights, chair and dental unit) and autoclaves for leaks, connections, replacement filters, door gaskets and bulbs. Have your team evaluate small equipment performance (scalers, curing lights etc.) as well. The last thing we want is unnecessary, emergency downtime or equipment failure after a long hiatus

Operations: 

• Be nimble. Be efficient. Analyze every office and operational process for an improved customer experience. Review proper PPE usage and how to respond to common patient questions about PPE, the virus and your protocols with your team. 
• Update your fees and be sure to add the new Tele-Dentistry CDT codes in your PMS. 
• Focus on minimally invasive care and evaluate how you can make procedures less invasive. Hand scaling when possible in lieu of the scaling machines (cavitron and Piezo). 
• Consider taking 3D or Pan Images in lieu of an FMX when possible. 
• Use your soft tissue laser and get a demonstration of the new combination (hard and soft tissue) lasers. You will be amazed at how effective and fast they are.
• Be sure to use Sesame, Demand Force and Lighthouse for marketing and patient engagement, not just appointment reminders. These tools are underutilized!
• Focus on prevention. Use silver diamine fluoride or other revolutionary medicaments to treat incipient decay. * D1354 interim caries arresting medicament application – per tooth Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure.
• Implement ‘next patient spacing management protocols’. Create patient staging points from the parking lot to entering the office and for the entire office visit. One suggestion is to have the next appointed person in the spare operatory. The next patient after them is seated in the waiting room and the next patient after them remains in their car until they are called on their cell phone. The goal is to create a patient flow that minimizes unnecessary contact with others that is directed by the administration team. 
• Cone Beam and Digital Impressioning units will become standard of care over time in my opinion. They shorten patient appointment times, improve your dentistry, identify clinical opportunities, enhance the patient experience and create an efficient digital workflow. 
• Use a touchless thermometers on each patient as they enter the office.  Have the patient fill out or answer a few questions before they come to the office to ensure that they and none of their co-workers or family members have or have had the virus to their knowledge. There are questionnaires floating around the internet or reach out to the local medical group or the ADA for suggestions. 
• Have an office policy regarding rules of engagement when a person with a fever or other symptoms arrives at the office for their appointment. Be mindful as some people are overly concerned about Covid and others are very lackadaisical about the virus. It is our job to be thoughtful and courteous. In the event that you encounter someone with symptoms, provide them with PPE and send them home or to a medical facility for evaluation and testing. Have a policy for staff members who show symptoms too. Be sure to document all of these encounters/events and follow up with that patient to show your concern. We live in a very litigious society.

Clinically Speaking:

• Embrace minimally invasive dentistry. Focus on early prevention of disease and incorporate a Caries Risk Assessment regimen for the office. Focusing on minimally invasive techniques such as arresting and reversing incipient caries, conservative caries removal will allow you to intervene with minimal invasive procedures (less drilling). 
• Focus on your hygiene and Perio department. It is the cornerstone of your business and refers over 60% of the operative dentistry you perform. 
• Embrace Teledentistry. Don’t appoint non-emergencies as emergencies, it can diminish daily production goals especially when you are seeing less patients per day. A simple TD video conference allows you to triage or qualify true emergencies
• Discuss basic practice economics with your team. They must believe that the clinical work you recommend and perform is required. Dentistry is a business and you’ll want/need longer appointments to deliver comprehensive care. This benefits the patient and the practice. The patient doesn’t have to return to the office for a second appointment and the practice produces more dentistry 
• Think unidose and disposable delivery systems when you buy your dental materials. In most cases, the cost is similar. A slightly higher cost may be justified if you’ve improved the patient’s perceptions about the practice and your cross-contamination efforts
• Substitute traditional air/water syringe tips with disposable ones. 
• Experiment with the newer generations of rubber dam products. They are easier to use and will eliminate a great deal of aerosols and saliva mist
• Use dissolvable sutures to eliminate a return visit that can be handled via Tele dentistry monitoring – the patient sends a photo to capture post-surgical suture healing
• Always use high volume aspirators in conjunction with low volume aspirators (saliva ejectors) even when you have equipped the room with an air purification system

PPE management/ Infection Control

We have all learned a valuable lesson about inventory management from Covid-19. Inventory levels on PPE should be increased based on utilization. This recommendation does not apply to all other sundries and dental materials. For most offices, one large monthly or bi-weekly order with an occasional fill-in order is appropriate. This is the most efficient ordering cycle, especially when dealers bill you monthly. This keeps the team focused on patient care with less interruption. Offices that order dental supplies more than once a week should reevaluate their processes and priorities. This creates unnecessary shipping costs, distractions and unexpected visitors when we are trying to create safe, uncrowded patient zones and waiting areas. 

• N95 and KN95 masks
• Disposable gowns
• Impervious patient aprons
• Face visor w/shields
• Eye protection [goggles] for staff and patients
• Surgical bouffant 
• Shoe covers 
• Gloves
• Office cleaning/ disinfectant products
• Aerosol compliance and ventilation products
  

Employee policies: 

• Keep copious health records and monitor all employees for signs of sickness 
• Have your employees sign off on personal and professional hygiene protocols
• Be sure to have a questionnaire that asks about family, friends and neighbors that may have been exposed to the virus
• Update your employee handbook to discuss policy, expectations and benefits for future emergency events
• Testing – determine your policy and legal obligations for Corona Virus testing as these guidelines are subject to change
• N95 mask fitting guidelines and testing *please contact the ADA or your local dental society for guidelines. 
• Keep a real time record of associate and hygienist licenses and track CE compliance 

Finance and patient financing:

• Accommodate patients that have financial insecurity or postpone treatment because of finances. Many patients were furloughed, displaced or are concerned about their ability or their sensibility regarding spending money on non-essential procedures. Do you offer patient payment plans, deferred payment programs or third party patient financing solutions? Most offices offer some assistance but not all offices have made these solutions part of their culture. Your team must be fluent and effective presenting these critical tools
• Consider billing the patient for the increase in PPE protection supply costs? There are lots of discussions on the web surrounding PPE billing practices. Many KOL’s suggest you charge a fee for the additional PPE and others say it is part of doing business. For the proper use and indication of CDT code D1999 – unspecified preventive procedure, contact your dental society or a coding specialist like Dr. Charles Blair, Patti DiGangi, RDH or Theresa Duncan, MS. *Discuss this matter with your accountant, neighboring dentists and your advisors before implementing a fee or not. 

Marketing and Reputation Management:

• Retailers and service businesses were challenged before Covid-19 by the growth and popularity of e-commerce. Covid has intensified this challenge – work on your digital footprint and reputation!
• Step up your community engagement and philanthropy. Your reputation and your customer service will determine your brand in your community. 
• You will experience a heightened level of competition post Covid. Enhance your customer service and web and social media prowess.
• Update your on hold answering message, update your website with new protocols and important websites and phone numbers for your patients to call regarding Covid-19. You are their resource for the latest information and guidelines. It is a big responsibility for all healthcare facilities. 
• Remember – Your digital reputation is your reputation!

Tele-Dentistry

• If you haven’t integrated Tele Dentistry into your practice yet – do it now. Covid-19 has made it a necessity and I believe we have not seen the last of these viral and biological outbreaks
• Meet new and existing patients virtually
• Discuss treatment and home care with patients.
• Qualify emergencies, and monitor post-surgical healing (suture absorption) and chronic conditions like periodontitis with synchronous video conferencing.
• Make preliminary diagnoses with images sent from the patients smart phone
• Use Tele Dentistry for emergency, mobile and mission dentistry as well as selling cosmetics and aligners at health fairs etc. 
• Contact your Henry Schein rep or the local dental society for the latest dental codes regarding Tele Dentistry.  *In some states, Dental Therapists are using Tele Dentistry, under a clinician’s virtual supervision, creating a new revenue stream for the dental office. 

Transitions:

• If a practice transition was on your mind before Covid, continue the hard work to have a clean balance sheet. This will improve your EBIDTA score and will yield a higher buying price (multiples of EBIDTA)
• Some experts believe the market, in the short term, has less buyers and more sellers. Sellers are concerned that the V curve may actually become a W after the Post-Covid surge which would delay retirement and exit strategies
• Get your cash flow and production numbers up
• Improve your facility by adding the technology a young dentist or dental group would desire.
• Ideally, begin your planning and strategy at least eighteen months before you plan on selling or merging your practice
• Speak to your dealer representative before signing a contract with an independent practice broker. They will provide you with real-time practice valuation information and may have some viable connections for you 
• Always be growing. Develop a game plan for future growth & success even when you have plans to transition. Everyone wants to buy a thriving practice 
• The new EBITDA is like the old EBITDA and is still largely based on cash flow and your net/net. However, when there are more sellers than buyers, compounded by marketplace uncertainty, other factors begin to matter as well. Expect buyers to look at higher PPE costs and how that impacts your supply expenditures. Post-Covid, there will be more scrutiny on your facility, how much technology you have, your level of insurance and other plans you may be a panelist on. All of these factors will affect the types of offers you will receive!

This crisis has been a metamorphic event, leaving us to navigate a new set of normal in a not so normal time. As history suggests, even in times of crisis and catastrophic events, some people flourish while the majority don’t.

I urge everyone to get past the politics and anger and begin the hard work to recover. Choose your team and business partners carefully. Over the next few years we will see many changes in our dental business. Some of these changes will be advantageous and others may present challenges. These changes will determine the course and relevance of dentistry in America for the next decade or more. 

This moment in time is your opportunity to differentiate and grow your business. Dentistry is a wonderful profession and dentists make a great living. Of all the investments you can make today, investing in yourself and your practice may be the best bet you can make!