Folks, Let's Be Smart…

Let me start with as much clarity as I can convey that I AM taking this Covid-19 virus seriously. This week, I spent 2 hrs on the phone with my parents who are both in the highest risk group. They’re both over 75, my mom has multiple sclerosis and my dad is 5 weeks removed from a kidney transplant and is as immunocompromised as they come.

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Both of my parents fall into the “70-75” age group but their susceptibility, because of their immunocompromised systems, is much higher. This is a VERY real situation for me.

I’ve also (like may of you) spent the last 4 or 5 weeks glued to the CDC and WHO websites watching what’s been happening well before the virus started growing in the US. I’ve always been fascinated by epidemiology and this has been a remarkable time to watch the global pandemic situation.
So, my comments below shouldn’t be misconstrued as ambivalent or not caring about every single soul affected by this horrible virus.
We’ve all been reading articles penned by, and podcasts including experts from the medical fields. Social media has been full of stories about “My friend the infectious disease specialist told me…” and “My family in South Korea said…” and so on. We’ve been lucky enough to see academic articles on the spread of Coronavirus in the dental setting and most of us have made videos or sent letters to our patients explaining the situations in our offices.
Next came lots of conjecture. “What are you going to do in your office this week?” The answers included everything from following the ADA recommendations to the letter, to closing up shop, to having people wait in cars until their appointments, to “not much else because it’s just like the flu and we’ve always used universal precautions.”
Are we really going to tell people to stop wearing aligners and elastics indefinitely because it causes them to put their fingers in their mouths and we can’t trust them to sanitize afterwards?
We’ve seen enough graphs and charts to make our heads spin and everyone telling us what they know “for sure” when we’re truly in uncharted territory. It is 100% true that if we “can stop the virus now, our healthcare system might not be overburdened.”
But here’e the thing: We’re not shutting down. Go on social media to see proof that while schools are closed, the common gathering places like malls, supermarkets, coffee houses, gyms, Costcos, churches, nail salons, dentists, doctors, parties, etc are still happening. All over the county. Borders are open. Interstate travel is open. Pediatric dentists that I personally know have added days into their schedule because of all the parents wanting treatment RIGHT NOW because of the fear of potential loss of insurance due to perceived layoffs due to the economic impact of many of the necessary preventative measures.
Yet, orthodontists-arguably the least invasive practitioners in dentistry-are considering shutting down their offices, or perhaps being shut down by the government. Is this the right approach? With all of the other areas of daily communal life still open, does shutting down your office really make sense?
On one hand, the idea that “I can make a difference” is somewhat true. If you shut down your office, less people have the opportunity to transmit to one another in your space. But until they stop going to church, supermarkets and all the other places listed above where they will run into and interact with WAY WAY more people in an environment that isn’t watching out for them, what difference does it really make? Are you sacrificing your livelihood and the livelihood of your team and the welfare of your patients who need your care for no really good reason? That is NOT a rhetorical question, but rather one we need to ask ourselves.
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How infectious is Coronavirus? The “R0” for Covid-19 is around 2-2.5 and the seasonal flu is around 1.4. For a virus to spread and survive in a population, it must be above 1.

If you REALLY want to know how China imposed a quarantine, read this article HERE and see that what we, as a society are calling for is nothing compared to what they did. But it raises a far more important question. It took over two months IN CHINA with what are being called “Draconian measures” for the virus to reach past its peak tipping point. And they need to continue the measures and they are FAR MORE vigilant than we will be.
So, if you’re thinking of shutting down your office for a week or two, think about this:  It’s going to take months for this to pass if we want to look at China or Italy or South Korea as an example. Are you prepared to shut down or delay your patients’ treatment for 3-5 months? Moreover, looking at this from a logical standpoint, if you’re truly worried about transmitting this disease from patient to patient, and you’re going to close when there are 1600 active known cases in the United States, shouldn’t you FOR SURE be closed when that number hits 20,000 or 50,000 or 500,000? What’s the sense in closing for two weeks and reopening when the chance of a known carrier in your office is much more likely.
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Testing in the US has been pretty light considering we’re “quarantining” the population. Due to the non-severity of symptoms in the general population and the similarity to colds and flu, the number of actual cases is probably much higher than the estimates.

My point is that let’s not -as orthodontist and NOT epidemiologists or infectious disease experts-decide what’s the right or wrong path. Let’s not get on to social media and say “My wife is a doctor and she suggested..” or “My friend is an epidemiologist and he suggested…” or “My practice financial manager/CPA put out a letter that suggested…”.
The economic impact is uncertain. People aren’t making orthodontists a priority right now and the idea of us being out of business AND having to pay our team can be downright frightening for those starting their practices. As of the writing of this article, the Coronavirus Jobs Bill  (learn more HERE at the NY Times article) might affect us because of paid leave but also states “…and the Labor Department will have the option of exempting workers at any company with fewer than 50 employees, if it determines that providing paid leave ‘would jeopardize the viability of the business as a going concern.’ ”
I appreciate it when I hear orthodontists say: “I’m going to pay my team even if it means that I can’t take a salary” and while admirable, is that really viable in the long-term? If your office is shut down for 2, 4 ,8 or 16 weeks, at what point does your family have to play a role in this? Are you ready and certain that the financial policies you enact right now are implementable in the longer-term? I’m just suggesting that you think wisely before implementing any policies.
Let’s listen to the protocols and procedures suggested by our parent organizations and do the best we can to protect our patients, ourselves and our team members. There ARE resources out there and we should try to follow their ever changing suggestions as best we can. The ADA suggestions HERE apply to dentists , who create an aerosol using water on virtually every patient (we drill far less and never use water) so these should be more than enough for us. A great article on dental aerosols is HERE. (Note that there is A LOT on the web about dental aerosols when one is using water, but very little about what we as orthodontist do with just air or even a slow speed alone.)
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I explained to my parents that while many of us are taking precautions, as high risk individuals, THEY are in charge of making sure they protect themselves. They must wear masks and gloves when handling anything that comes through their door, set up a “containment zone” as best they can and they shouldn’t rely on anyone outside of their door being able to keep their home a virus-free environment. However, the fear mongering folks out there created an environment where my parents-the highest risk- cannot obtain masks or gloves or even the most simple disinfectants necessary because of the hoarding that’s happened.
THAT’S the real danger in this situation. People (us included) making decisions based on fear and over-reacting (as the public has) leaving many worse off than if they had done nothing.
These are unprecedented times for all of us. Most importantly, let’s not panic and make policies and protocols that don’t align with the recommendations of our governing bodies. Let’s stick together and help one another and no matter our personal opinions based on what we’ve heard or seen, none of us knows better than the CDC and the organizations making policy. This isn’t going to go away in a week or two, and things are likely to go through multiple iterations.  Let’s watch it unfold and help one another.
We MUST act to “flatten the curve” of the spread of this virus. We MUST do what we reasonably can to protect our patients. Let’s just not make hasty decisions based on emotion rather than what is being recommended.
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This will pass. Life will go on and we will hopefully learn from this and do an even better job the next time we’re faced with this kind of crisis.
Wishing you the best,
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  1. Greatly appreciated your perspective. I vacillate back and forth about what we should do with our practice to remain responsible to our patients, our employees, our families, and our business. So many moving factors to consider. Thanks for sharing your thoughts-