Special Report: Coronavirus

The American Dental Association (ADA) on March 16 called upon dentists to postpone elective procedures.

"The ADA is deeply concerned for the health and well-being of the public and the dental team," the organization says in a statement. "In order for dentistry to do its part to mitigate the spread of COVID-19, the ADA recommends dentists nationwide postpone elective procedures [through April 6]. Concentrating on emergency dental care will allow us to care for our emergency patients and alleviate the burden that dental emergencies would place on hospital emergency departments."

As of mid-March, the virus was continuing to spread, and an increasing number of dental laboratories were feeling the effects.

COVID-19 is a betacoronavirus, a family of viruses that have their origins in bats. Many of the first patients diagnosed with it in Wuhan, China, had some link to a large seafood and live animal market, suggesting animal-to-person spread. However, the virus has been spread from person to person since then.

The virus has resulted in illnesses ranging from mild to severe, with some resulting in death, but the complete clinical picture is not yet clear, according to the Centers for Disease Control (CDC). Symptoms can include fever, cough, and shortness of breath, and they may appear anywhere within 2 to 14 days after exposure.² As of March 17, there was no vaccine to protect against the virus and no medications approved to treat it.

A study examining the first 45,000 cases in China found that 80% appeared to be mild,³ affecting more older patients than younger ones. The same study found that patients younger than 20 accounted for only 2% of cases. The virus had an 8% mortality rate among those in their 70s and 15% among those in their 80s.

The WHO's March 16 Situation Report listed 167,515 confirmed cases globally, and 6,606 deaths.⁴ While 78,961 of the first 83,652 cases were in China,⁵ by March 16 China accounted for less than half of the total.⁴ The WHO's risk assessment has been "Very High" since February.⁵

In the US, approximately 5,000 cases had been confirmed through March 17, with the death toll approaching 100.⁶ The CDC lists the phases of a pandemic as investigation, recognition, initiation, acceleration, and deceleration; the peak of illnesses occurs at the end of the acceleration phase.¹

"The United States nationally is currently in the initiation phases, but states where community spread is occurring are in the acceleration phase," the CDC stated on March 15.

The immediate risk of exposure to the virus was still described as low for most Americans as of March 17, but that risk was expected to increase with the expansion of the outbreak.⁴

The CDC says it "may be possible" to get the virus by touching a surface or object that has the virus on it and then touching one's own mouth, nose, or eyes, but that this "is not thought to be the main way the virus spreads."⁷ Definitive statements on that subject had not been published as of March 17.

"The CDC has not said, ‘This virus can live a certain length of time on certain types of surfaces,'" says Mary A. Borg-Bartlett, President of SafeLink Consulting, Inc. "They have alluded to the fact that that is still under evaluation."

Also unknown is whether the virus will subside in the spring and summer, though even if it does, it could return in the fall and winter each year.⁸

"It could become a seasonal flu," Borg-Bartlett says. "A vaccine may be developed, and hopefully by next fall medical professionals will know more about how to treat it. It is definitely being worked on."

To guard against the possibility of an employee inadvertently introducing the virus into the laboratory, Borg-Bartlett recommends reviewing the CDC's 2003 infection control guidelines for dentistry and the summary published in 2016.¹¹

"The dental laboratory definitely needs to monitor its own staff," she says. "If they are sick, they should be sent home."

A second possibility for person-to-person contact is less predictable: Patient interaction. While the CDC has provided suggested screening questions for dental offices to ask patients, dental laboratories are not permitted under HIPAA to ask those questions directly. Thus, the laboratory must rely on the dentist when sending a technician to work chairside or hosting a patient for shade verification services.

"Our opinion is that the dental laboratory should be assured by the dentist that any patients being sent to the laboratory for a shade verification or for any other reason have been screened," Borg-Bartlett says. "For chairside services, which are becoming increasingly common, the laboratory owner has always been responsible for the technician who is being sent into the dental practice. The dentist is also responsible for protecting them. Either the dentist needs to provide the personal protective equipment to that technician, or the employer needs to provide it to ensure that they are following standard and universal precautions while that technician is in the dental practice."

Of course, these precautions are not completely foolproof, especially with a virus that has been shown to be contagious even when no symptoms are present.

"Some laboratories may want to discontinue direct patient services for the time being if they or their own employees are concerned," Borg-Bartlett says.

Laboratories that outsource some of their work should consider a broader range of precautions. It is no secret that a significant percentage of dental restorations in the US are fabricated overseas—whether sent directly by dentists, by laboratories with full disclosure, or, in some cases, by laboratories that do not disclose the practice. Approximately 8.6% of laboratories in a 2019 National Association of Dental Laboratories (NADL) survey said they outsource at least some of their work overseas. Only 11 states require laboratories to disclose point of origin.

The US government has imposed travel restrictions due to the coronavirus but has not restricted imported products.⁹ While the CDC has not made a definitive statement about it, studies indicate that human coronaviruses in general can persist on inanimate surfaces such as metal, glass, or plastic for up to 9 days if not inactivated via surface disinfection procedures.¹⁰

"We do not know what COVID-19 lives on," Borg-Bartlett says. "That is somewhat alarming."

As such, Borg-Bartlett's consulting firm has issued guidance to dental laboratories suggesting that they require any offshore partner laboratories to disinfect restorations prior to shipping—something that is not standard practice and even in the US is required in only two states—and note it with a sticker on the package.

"We do not know whether COVID-19 could travel on packaging or the restoration itself," Borg-Bartlett says. "We believe it is incumbent upon any US laboratory importing from another country to inquire of that offshore laboratory whether it is disinfecting, and if not, to consider requiring it. Make sure that laboratory has met the criteria published by the Environmental Protection Agency regarding emerging viral pathogens."

In China, the initial epicenter of the outbreak, some laboratories shut down their operations entirely—which proved to be a boon for US laboratories that that do not send work offshore.

Jason DeFranco, President of Team Solutions Dental in Sanford, Florida, says several of his new clients were told by their previous laboratories that they would not be accepting any new cases and had no estimated time for the completion of cases already submitted to them.

"At that point, they started scrambling," DeFranco says.

The result for Team Solutions Dental, an $8 million-per-year business, was a 25% to 30% increase in the month of February.

Aurora Dental Studio in Auburn, New York, experienced a similar spike. COO Keith Miolen, CDT, knew that several of his dentists sent large portions of their work to China, so he began contacting them in late January.

"I told those dentists that if they ran into any issues, we would be there for them," Miolen says.

The result was exponential growth. One day, Aurora received 91 partial framework cases from one DSO.

"I had to call that client and say, ‘I have a three-person partials department, so the turnaround time on 91 cases may be longer," Miolen says.

Similarly, Patriot Dental Laboratory in Prescott, Michigan, had its biggest month ever in February, according to President/CEO Rob Teachout.

"We blew away our all-time records," Teachout says. "Of our five new accounts, four of them were part of a DSO and likely knew that their work was being sent overseas, but the fifth did not. He found out why he was not getting his cases back, and he found me online because I have been such a big supporter of keeping dental laboratory work in the United States."

Teachout says other potential clients have called to ask Patriot to match the prices they typically pay for work done in China. He declined, and they sent their work elsewhere.

"My goal is for the five accounts that we added to appreciate that the quality of our work is twice as good, and the customer service element of being able to discuss complex cases can save them significant time at the chair," Teachout says.

DeFranco and Miolen both say they hope to keep their new accounts as well.

"We acknowledge that most of these practices are sending where they are sending for a reason—whether it is price, a corporate mandate, or a contract," DeFranco says. "All that we have said to them is that we hope the value proposition makes them think about whether that is what they want to keep doing or whether they want to consider this as an alternative. A couple of them have said they will stay with us because of the inconvenience this situation caused; the fact that something like this could so totally sideswipe them represents a level of instability that they cannot trust for their business. Others have said they will stay with us because the delta between price points is insignificant when compared with our faster turnaround times and quality of communications. This is the same thing we have been saying to them for quite some time, so it is tempting to say, ‘I told you so!'"

DeFranco told these clients that his laboratory would be open to discussing volume discounts at a certain point, but not to the levels of the China laboratories.

"We will not directly compete with China," DeFranco says.

Miolen hopes his new accounts find the same value as DeFranco's have. He considers this to be an opportunity to make a strong impression.

"I am calling these clients and saying, ‘Let us know what you think. I would love to be here for you, so here is my cell phone number,'" Miolen says. "I am using this as a point to build business and hopefully retain it."

While most laboratories typically prioritize customer retention, it is particularly important at this time. DeFranco's 82-person laboratory was in a growth phase anyway, but Teachout hired two new employees for what had been a seven-person laboratory, and Miolen added two people to what had been a three-person partials department, specifically to deal with the increased workload.

"Building a business is difficult when you do not know how long the growth will last," Miolen says. "I do not want to put myself in a position where the work slows down and I am overstaffed."

Teachout says he is being selective about the accounts he adds, knowing some who contact him have no intention of a long-term arrangement.

"I cannot just take 50 new accounts overnight," Teachout says. "I plan to train more employees and add a handful of accounts each month or so. It is difficult because there is a group of dentists out there who had no idea their laboratory work was being sent to China, but there is a bigger group of them who were sending directly to China. I expect some of them to jump back once everything evens out, but I also expect many of them to stay because they have had to bring patients back in, take temporaries off, and re-impress, and they do not want to have that problem ever again."

While some laboratories are focusing on retaining the new business that came to them under unfortunate circumstances, others hope this is an opportunity to highlight the issue of disclosure.

The NADL has invested significant resources over the past several years in the "What's in Your Mouth" campaign, which aims in part to inform dentists and patients on where their dental restorations are coming from, who is making them, and what patient contact materials are used in the process. The coronavirus outbreak might finally help get the public's attention.

The NADL confirmed it plans to ramp up the campaign in light of the current situation. Eric Thorn, In-House Counsel for the NADL, writes in a recent blog post on the NADL's What's in Your Mouth website that the coronavirus is "a poignant example of why all states should adopt dental laboratory registration and material and point of origin disclosure."

"Imagine if a dentist were to place a COVID-19-infected import into a patient's mouth, given some sources that indicate the virus can live for 9 days on metal," Thorn writes.

He adds that the "proper disclosure ensures dentists and everyone in the dentist's office can make an informed decision for their patients."

Thorn says the NADL will continue to look for more ways to get the message out, and that it is more important than ever for laboratories, dentists, and patients to go to whatsinyourmouth.us and help spread the word through social media, websites, and other outlets.

Rafael Camarena, an in-house technician at PermaDontics in San Diego, California, says he hopes this situation spurs legislation in more states.

"This is a prime opportunity to shine the light on products going overseas and to get the attention of unknowing patients," Camarena says. "We need to raise awareness. We need laws requiring dentists and laboratories to both disclose where they send their work."

Of course, even laboratories that fabricate all of their restorations in the US often purchase some of their supplies from overseas.

"As soon as we heard it was getting serious in China," DeFranco says, "we sourced all of our materials to determine what vendors get supplies from China. It was a small number, so we called all of those vendors and bought up all of their supply."

Supply chains seem to have been largely uninterrupted, however. Miolen purchases many of his consumables from China, including a well-known brand of zirconia, and he says he has not experienced any disruptions. Two 3D printing manufacturers with factories in China say they were able to weather the storm: SprintRay Director of Marketing James Lobsenz says his company's annual increase in inventory prior to the Chinese New Year in February proved sufficient to offset the temporary disruption to the supply chain, and HeyGears Sales Manager Roger Wu says the virus has had limited impact.

"So far, we have not seen any material impact to our business, and we are not forecasting one," Lobsenz says. "Our employees are back to work and operating on a daily basis."

Wu says a few of HeyGears' employees have not yet returned to work, but that the primary impact on his company was some extended delivery times due to canceled flights from China to the US.

"The majority of China is now gradually returning to normal operation," Wu says, "so the impact is limited and the situation is getting better day by day."

As the virus continues to spread, its lasting impact on public health, the economy, attitudes toward infection control, and more remains to be seen.

NADL Chief Staff Executive Bennett Napier says the NADL has been in frequent contact with the ADA as both organizations are fielding more and more calls from their respective members about it. Until more is known about the virus, dental laboratories—like the rest of the general public—simply must exercise extreme caution.

"The bottom line," Napier says, "is both laboratories and dental offices need to practice what is already required for proper infection control."

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