More than just a whole mouth clean: what dental services might look like under the new normal

Metro Manila (CNN Philippines, May 27) — As the Philippines eases lockdown restrictions, the Philippine Dental Association says dental services may not easily return to where they were before the pandemic.

Medical representative Ainna Raga hasn’t seen her dentist since the lockdowns began last March. She wears braces and needs to have them fixed on a monthly basis, but cannot avail of the services due to the restrictions brought about by the quarantine.

“Halos three months na po akong walang adjustment at all sa braces ko, so ang ginagawa ko, nagsa-sarili lang po ako ng paglilinis ng braces ko kahit papaano,” Ainna said, as she narrated what she does to ensure that her braces are clean.

[Translation: I haven’t had brace adjustments for almost three months. This is why I clean my braces instead, somehow.]

Meanwhile, dentists Johnne Wayne Cuevas and Cristy Gollayan-De La Cruz are preparing their clinics for re-opening under the new normal.

As Dr. Cuevas made the rounds in the clinic where he works, he noted that risks are higher now compared to before the lockdown.

“Kung dati, prone na talaga kami to acquire these kinds of different illnesses, mas lalo ngayon because hindi mo nakikita yung kalaban,” Cuevas said.

[Translation: If we were prone to acquiring different illnesses before, the risk is greater now because the threat (of COVID-19) is invisible.]

Dra. De La Cruz, meanwhile, said clinic services have been limited to emergency cases, in line with guidelines released by the Philippine Dental Association (PDA) last April 26.

“That’s basically the problem because we cannot do everything that we used to do before like bridges or oral prophylaxis, restoration," De La Cruz said. "We can do restoration on emergency basis."

This is because the PDA adapted a similar view with that of the American Dental Association, which classifies dental services into two key procedures: dental emergencies and non-emergency procedures.

Emergency procedures include but are not limited to uncontrolled bleeding, facial bone trauma, painful tooth fractures, and the repair of dentures when the functions are impeded.

On the other hand, there are non-emergency procedures, which includes Ainna’s monthly braces fix - known to dentists as a routine monthly adjustment, and oral prophylaxis or periodic cleaning.

The PDA also classified procedures, depending on whether or not they can generate salivary droplets which, in turn, may form aerosols that can spread the coronavirus disease.

Aerosol Generating Procedures (AGP) are defined as those which may generate saliva outside the mouth and oral cavity, while Non-Aerosol Generating Procedures (NAGP) are defined by PDA guidelines as “dental procedures which do not use air driven or powered instruments inside the oral cavity.”

“Yung mga dentista, takot din kasi we don’t know kung anong pwedeng mangyari upon cleaning,” Cuevas said. “Posible kahit na hindi ka nagcreate ng aerosol, kung natalsikan ka naman ng laway niya, pwede pa rin (ma-infect).”

[Translation: The dentists are also afraid because we don't know what can happen upon cleaning. It's possible that even if it does not create aerosol, if the saliva transfers to us, we can still get infected.]

In Ainna’s case, Dr. Cuevas said it is an aerosol-generating procedure, as possible removal of ortho-brackets will require the use of a handpiece, an equipment which may generate aerosols.

"Kailangan nating linisin yung tooth surface bago siya makabitan ng bracket. That’s why, kapag tinanggal natin yung excess cement sa tooth surface, ang nangyayari, gagamit tayo ng handpiece or yung pang-drill," Cuevas said.

[Translation: We need to clean the tooth surface before we attach brackets. Once we remove excess cement from the tooth surface, we will need to use a handpiece.]

Once restrictions are eased though, the PDA said, dental appointments will no longer be the same as usual.

Thorough disinfection of the clinic before and after procedures are also required, and dentists and dental staff will be required to wear complete protective gear.

Walk-in bookings will also be shelved in favor of online appointments, which will allow dentists to thoroughly check on their patients’ medical history.

“We do triage by calling the patient first and asking pertinent questions to at least screen the patient at that level,” PDA President Dr. Steve Almonte said.

Almonte added that prices of dental services may go up as clinics come with necessary expenses in order to protect their clinics from the coronavirus, including the purchase of new machines and equipment as well as retrofitting clinics for better air circulation.

“It’s like starting all over again. That’s the saddest part about Philippine dentistry now,” Almonte said, adding that “there is no other way to actually lower the prices, much more maintain it. In fact, it will affect HMOs (Health Maintenance Organizations).”

Almonte said the expenses of retrofitting clinics to adhere to what is known as the “new normal” may also take ₱50,000 to ₱100,000, depending on clinic size and location.

This raise in prices is worrying Ainna, who fears that availing of her monthly dental service may clash with her monthly expenses.

"I’m worried kasi yung sa braces ko po, is ₱1,000 yung adjustment ko every month, so if it goes beyond ₱1,000, baka mahirapan po ako kasi baka sumabay din po yung ibang bilihin sa pagtaas," Ainna said.

[Translation: I’m worried because my brace adjustment already costs P1,000. If it goes beyond that, I might find getting dental care a bit more difficult because it will coincide with the rise of other expenses.]

In light of this, the PDA is also urging government officials to start investing more on public health dentistry.

“That’s why its important that the government would also support the government dentists,” Almonte said. “This is so they can help those who cannot afford to go to the private dental clinics.”

Almonte appealed to the public for understanding, saying that dentists are also adjusting to the new normal and are “taking it slow” in terms of incorporating dental practice once again.

“During the lockdown, March 15th, we adhered as much as possible to emergency procedures, or so-called non-aerosol generating procedures," Almonte said. "What we’re now trying to tell dentists is to get the grasp of how to slowly incorporate dental practice again to their staff, to their patients. Parang nagsisimula ka pa lang. [It’s like starting over again]"

Nevertheless, Dr. Cuevas and Dr. De La Cruz continue to prepare their clinics for when they are again allowed to take in patients in need of dental care.

“You really have to be strong,” Cuevas said, having spent only three years in the industry. “Walang kasiguraduhan kung hanggang kelan to. Yes, lugi na, because for two months, hindi rin nagwo-work, only emergency cases. Ang nangyayari kasi is yung takot ng bawat dentista ngayon, ‘what if we get infected while doing our duty?’ For me, hindi malinaw kung hanggang kelan kami magtitiis sa ganitong sitwasyon.”

[Translation: When this whole thing will end remains uncertain. Yes, we’ve been in the red. We haven’t been working for two months, only emergency cases. But dentists feel the same – what if we get infected while doing our duty? How long we will endure this situation remains to be seen.]

Meanwhile, Dr. De La Cruz, who has been practicing dentistry for over 15 years now, had this to say as she showed us through her clinic in Quezon City.

“When you’re earning, you have to set aside something,” De La Cruz said. “There were a lot of opportunities na nawala, so wala tayong magagawa doon. What makes me cope up with it is just God."

[Translation: There were a lot of opportunities lost, and we can’t do anything about it. What makes me cope up with it is just God.]

PDA chief said he believes that dentists have a major role to play as far as health is concerned.

"To the community, to the general public - We are doing our roles. Before, we were actually placed in a bad light for not opening our clinics. But now, we do hope that everyone would understand why we did such a move," Almonte said. "The danger of COVID-19 is real. By now, I guess, I hope they understand perfectly what’s happening to our country."

The association also reminded the public to find ways to practice oral hygiene, saying that proper oral care may be achieved by brushing twice daily using highly-flouridated toothpaste, gargling using mouthwash or warm water with salt, flossing, and reducing the intake of sugary and sweet foods.