The Group Dentistry Now Show: The Voice of the DSO Industry – Episode 22

In light of COVID-19 and the additional infection concerns it brings, Dr. Dan Davidian, founder & medical director of Anutra Medical, discusses why dental practices need to become more efficient, with systems and products to support that goal. He explains how dentists should move towards an environment of limiting points of contact with patients, multiple patients and patient to patient contact, for the patient’s safety, the dentist’s safety, and the staff’s safety. Limiting points of contact, in turn, also reduces the amount of PPE needed.  If you are looking for ways to practice dentistry in the post-COVID-19 ‘new normal’ – this audio-only podcast is for you!

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I’d like to welcome everyone to the Group Dentistry Now Show. I am Bill Neumann. Today on our show, we have Dr. Dan Davidian. He is the founder and medical director of Anutra Medical. First off, welcome to the Group Dentistry Now Show, Dr. Dan.

Dr. Dan Davidian: Thank you. Thank you for having me.

Bill Neumann: Dr. Davidian is the founder of Anutra Medical. Anutra Medical’s products, they neutralize and deliver dental anesthesia, and we’ll talk about that later on in the podcast. Dr. Davidian graduated from the University of North Carolina School of Dentistry with his DDS degree. He has completed additional training in advanced life support skills at UNC and also received his sedation training with the American Dental Society of Anesthesiology. Dr. Davidian trained at Ohio State in advanced airway management. He also trained at the Medical College of Georgia and received his IV sedation certificate, as well as additional advanced life support training.

Bill Neumann: It sounds like you have a lot of training here, so I won’t go into all of it, but again, thanks, Dr. Davidian, for being on the Group Dentistry Now Show today.

Dr. Dan Davidian: Thank you for having me.

Bill Neumann: Obviously, a historic time in the dental industry, to put it lightly. We’re going to talk a little bit about what the entire dental industry is going through right now with the COVID-19 crisis. I’m wondering, why don’t we start off the show by asking you a simple question? Maybe it’s not so simple, but what do you see as some of the biggest challenges for providers and then also for the patients as we work through this, as we come out of the COVID crisis and we go from stay at home to opening up our practices?

Dr. Dan Davidian: At first, I do want to start by kind of saying as medical providers and as dentists, I do feel like it is our obligation and our oath to our patients to be seeing our emergency patients. As a whole, as a community, I feel like we need to … Our healthcare providers and our nurses are seeing patients and they’re seeing emergencies and they are risking their health to see those patients. I think many dentists are sitting on the sidelines and kind of waiting for the green light to go ahead back to work and aren’t seeing emergencies or anything.

Philosophically, I do feel like you’re shuffling these patients to the emergency room or urgent care facilities or even just the oral surgeon. I feel like should be at least trying to get back into the swing of things as soon as we can just out of obligation to our existing patients.

But I would say that the biggest challenge we have with the stay at home is once we do re-engage in our practices, just getting that machine working again, getting the kind of the parts moving, getting the cohesion of the employees, getting them to want to come back. A lot of them are on unemployment and making just as much money as they would in our practices.

We also have the difficulty of just getting the patients to feel comfortable leaving their houses, getting to our practices, getting in the front door, helping them feel safe, and getting them to value our dentistry, that we’re going to be asking them to commit resources, that many of our pockets are stretched, and we’re going to ask them to commit resources that might go elsewhere. Kind of convincing and messaging them on the value of what we do is going to be very, very important, especially over the next few weeks and months.

This is kind of the time when we are going to have a little extra time. It’s going to be a good time to start focusing on those systems and products that will help make us more efficient. When we’re not as busy, they’ll be a lot less disruptive to our patient flows. A lot of the things that we’ve kind of avoided in the past integrating into our practice because of the any kind of practice disruptions, it might be a great opportunity to do that. That’s kind of where I feel like one of the biggest things we’re going to be looking at as we get back into the system.

Bill Neumann: Yeah. I think you’re right. There’s a lot of … It sounds like, talking about moving parts, there’s a lot of different things. It’s the mindset of the patient, the mindset of the employees, making people feel comfortable on both sides, maybe not having enough money or being a little bit, from a patient perspective, being a little bit more cautious with how they spend their money, the caution regarding patient safety and employee safety. You’re right. I think what a lot of dentists and DSOs are doing right now is you have a lot of time to plan. What are you going to do differently post-COVID? What are you going to need to do differently? You’ve got time to plan now.

Let’s talk about a couple different things. I think the way the dental practices operate may look a little bit different or a lot different post-COVID. Typical dentist may juggle, certainly juggling different balls, different procedures, day in and day out, moving from operatory to operatory. Just as a for instance, you have a patient that may need to be anesthetized for a procedure that takes 10 to 12 minutes. Then the dentist may go and do something else, see a couple other patients. Do you think that that patient flow is going to change? Do you think you’re going to be able to move around at least short term like that?

I definitely believe that the face of dentistry and how we treat patients is going to be dramatically different. I think it will be awhile before we’re seeing the traditional hygiene schedules that we are used to. Although I’m a big proponent of getting back into continuing care, preventative care, I just saw a patient earlier this year who I had diagnosed with neck cancer. I found a lump on Monday. They were the EEG on Thursday, and then ended up getting it removed, and it was cancerous, that following Monday.

I think a lot of people undervalue what preventative care and what going to the dentist really is. But with that being said, we probably will start our hygiene protocols with the more of the anesthetic driven care, the periodontal patients and the peridontal therapies, which in many of our practices, we have patients on three to four month recalls. Those patients may be on schedule or off schedule by a few months, but delaying them for a month or two may not be the end of the world. But many of these patients, if you put them off six, eight months are going to be in a situation where their periodontal health has diminished to the point where they might need periodontal scaling, which creates an added expense. Sometimes people don’t follow through with that. As we know, periodontal disease is linked to heart disease and diabetes and all of the comorbidities that we’re trying to avoid with this COVID.

I do feel like we are, as a community, going to need to kind of embrace getting back into some of the preventative care and certainly the periodontal care. Setting that aside, I do believe the bouncing around and seeing a patient and numbing them and going to another patient and then coming back to see that patient, there’s really going to be a migration away from that. We’re going to really move towards a environment of limiting our points of contact with patients, multiple patients and patient to patient contact, for the patient’s safety, the doctor’s safety, and the staff’s safety. Not to mention, if we’re bouncing around, the additional use of PPE is going to be tremendous. I see this kind of picture of what the regulations are coming down, what kind of PPE are we going to be required. A lot of people are suggesting we’re going to be wearing hair nets and shields and N95 masks, and some people suggest we’re going to be wearing booties and disposable gowns, which we do a lot in the OR kind of situation. But I’m kind of looking at that situation where you’ve got significant PPE on and you’ve got to … You get all that on, you sit down and try to numb a patient out, then you got dirty gloves, so you got to take those off, put clean gloves on, take all that PPE off, go to another patient, put it all back on, re-glove, see that patient, then throw those gloves away, put new gloves on.

I see this scenario of the more PPE that we add bouncing around is not going to be the right answer from a financial perspective, just the waste of the PPE. We are being asked to conserve PPE. Then just from an efficiency point of view, it’s really going to have a dramatic effect. Currently, I’ve been seeing a little bit on an altered schedule based on the fact that my anesthetic protocols changed, which allows me to kind of sit with the patient, stay with the patient. I did it mainly for the efficiency that it created and the financial considerations, but now more than ever, it’s going to be not only that, but just limiting the point to point contact of the patients and limiting and conserving the PPE from a functional standpoint and a financial standpoint.

Bill Neumann: Yeah, absolutely. I didn’t even really think about that, but yeah, as you move from one patient to the next, you may have to spend an exorbitant amount of time changing the PPE that’s already in short supply. It just doesn’t make sense. Certainly from a patient perspective, there’s going to be huge frustration, the additional time that would be involved.

That really leads into the next question, patient perspective. It makes sense that everybody’s going to be nervous, everybody being patients, getting back into this unknown environment for a while anyway where they’re not comfortable. So you think that the traditional dental appointments going to have to change? That’s kind of what you’re saying. It’ll be same-day treatment. Do you think that’s just going to be the norm regardless of what the appointment’s for? What are your thoughts there?

Dr. Dan Davidian: Absolutely. I think we are going to be in a situation for several reasons. The fact that none of us have been open for a while means that we don’t have a lot of patients scheduled out two, three, four weeks out in advance. When we open our doors, we’re going to start seeing emergencies.

Now, seeing those emergencies, it’s going to make a lot more sense to see the emergency, have a protocol that will allow us to do some same-day treatment on that patient for several reasons. The economic benefit is we need the production, we need the money coming through our practices. Then from a patient protective standpoint, you’re triaging them and trying to bring them back another day. Number one, you’re adding a whole other layer of PPE that you have to reuse, you do today and then you got to reuse some tomorrow, so you’re not conserving your PPE. From a patient safety standpoint, it’s the right answer to kind of try to do some same-day treatment and more of stay with your patient type treatment.

Patient safety, from conservation of PPE, and from an efficiency, as I’ve been practicing like that for the last five years, it’s tremendously more efficient to stay with your patient than it is to start bouncing around. Most of the times we’ve been moving around from patient to patient based on the inadequacies of the anesthetics. I talk a lot about that when I do lectures about why our systems are fairly antiquated and now is a good time to really look at what are our protocols and systems and how do we evolve into kind of the new normal.

Bill Neumann: Yeah. The new normal has been … I think that it was originally coined during the Great Recession, but we’ve brought it back for the COVID. It certainly hits much closer to home when it comes to dentistry in a new normal. In dentistry, this new normal, what do you think the biggest single change would be for not just individual offices but the multi-site or the DSOs, from an employer standpoint? Do you have any thoughts on that?

Dr. Dan Davidian: I do. I really feel like it is going to be that this time where we’re going to have to sit back and really evaluate our practices as a whole and how we do things, and from an economic standpoint and from a staffing standpoint and how … We have a lot of patients that are already apprehensive of coming to the dentist. They’re going to be going avoiding the dentists. You give them any reason to avoid the dentist, they’re going to avoid them. Our emergencies are going to be a little bit bigger. The governors are saying stay at home. You’ve got the natural fear of getting sick to stay at home, and then you have the natural fear being at the dentist to stay at home. A lot of these routine type procedures are going to get put off more and more and they’re going to become much more emergent and much more significant over time.

I had a patient that came in last week that had routine care back in January. Diagnosed an MOD on tooth number 19. Patient didn’t get in right away. Then COVID hit, hadn’t gotten in. Came in last week and the whole lingual cusp was fractured off. Now that patient went from needing a filling to needing a foundation crown. Their doctor recommended they don’t get their dentistry done because they want to say that we’re not essential. Now that patient is going to go another few months without the necessary treatment.

As we know, broken teeth can turn into fractures or lost teeth. They can turn into root canals, foundations, and crowns. We’re going to start seeing this delayed treatment turn into more significant, more urgent type situations over time. I think it is going to change the face of what we schedule and how we schedule it as individuals and as group practices.

Bill Neumann: Yeah. That makes a lot of sense. The longer people aren’t going to the dentist, the more healthy people that have relatively healthy mouths are going to be in a situation where some of the things that maybe have been put off or weren’t determined because they missed one of their six month checkups all of a sudden becomes something that would be considered emergent care and didn’t necessarily have to be. That’s really interesting, and that could go on for quite a while, especially with the fear factor that some patients may have.

Dr. Dan Davidian: Yeah. It’s an interesting thing. I think there is going … You’re going to start seeing a change over time, but you have a lot of pediatric dental offices that were encouraged not to do general anesthesia over this period of time. It seemed like the right answer, but the unintended consequences of delaying these patients being seen for a month, now they’re seeing a lot more children with emergent situations and they were recommended not to do general anesthesia.

One of the issues now that they’re facing is now they’re going to end up … They’re seeing these emergency patients who have to be more held down and papoosed. As a dentist who treats high fear patients, that’s what creates a lot of these high fear patients. I think as we as dentists band together as a whole, we really need to speak loudly about the unintended consequences of some of these regulations that on the surface seem kind of to make sense.

Now you’re seeing the consequences of not seeing patients for a month. They really are going to be … They’re already going to be significant. I think it was the right answer for where we are now, but it’s time to start letting the reigns up because I think people aren’t going to … They’re going to see a lot more of those kind of stories kind of panning out.

Bill Neumann: Yeah, absolutely. Let’s talk about safety in the offices. You have some recommendations on how DSOs and dental practices can kind of … What steps would you recommend and how are you going to implement them to keep an office safe for not just the patients but also the employees in this post-COVID dentistry, once you’re able to get out and practice again?

Dr. Dan Davidian: Yeah. It’s going to be a struggle. I think as the individual states start putting their own guidelines and the individual boards start putting their own guidelines, we’re going to have a much better picture of what that safety looks like. I think now it is our obligation to keep our staff as safe as we can. I think the best way is doing as much of the protective equipment for ourselves and our patients. Some of it is going to be pomp and circumstance just to help our patients feel more comfortable coming into the dental office and they see that you are taking every step that you can to treat them as safely as possible.

I do think … We did talk about just the PPE thing earlier as far as just the amount of it is going to change and then how we practice and conserve it is going to change. I know we are probably going to have to as a community, group practices and single practices, really look at some type of facility fee that’s going to cover our PPE costs. A lot of surgery centers do facility fees. A lot of hospitals do facility fees. When I get my oil change, they have a recycling fee. When I get a new appliance, they have a recycling fee.

I think our office is definitely looking at doing some type of way to cover the protective equipment that we need for several reasons, and it’s not just the expense of it, but I think facility fees, encouraging facility fees, will take those dentists who might be unlikely to embrace all of the regulations and not use the appropriate PPE. If they’re able to charge $10, $15, $20 for a facility fee, they’ll feel much more comfortable. It will take the barriers to entry of them buying the protective equipment.

These N95 masks used to cost $1.50. Now they’re $4 each. You could go through, in a surgical procedure, if you have two, three staff in the office and equipment … It may get costly. I think one of the things is some kind of facility fee to kind of offset that as well.

Bill Neumann: Yep. I’ve heard that tossed around a little bit. It make sense. I think it also makes the patients aware that you’re committed to their safety. They see that line item, so to speak. They understand what the cost is and it needs to be recouped. Yeah, that makes a ton of sense.

Here’s a big question then. Once we’re through this, hopefully sooner rather than later, how do you think patients are going to value dentistry? Do you think they’re going to value it more? Are they going to value it less? Do you have any thoughts on that?

Dr. Dan Davidian: It’s interesting. I think in the short run, I’ve been very disappointed on how dentists have been valued through their own actions and through outside actions of a lot of the healthcare professionals, kind of telling, kind of implying a lot of dental offices should close and should not be doing dentistry. I think that is disheartening.

I think that we will start to see the value increase dramatically as we start to realize, and as we talked about earlier, the unintended consequences of leaving this preventative care for months at a time. You’re going to have patients really realizing that when they come in with that broken tooth that could have been a filling six months ago and now it’s a crown, I think the value is going to increase.

I think it is an interesting season right now where we are going to start … I think we’re going to start seeing a migration. We fought against the stereotypes of dentists not being real doctors for a long, long time. I think we need to fight the stereotypes and really practice dentistry, practice preventative dentistry. I think we need to message it to patients and help them understand why we do all of the things we do and why it’s not just elective type procedures and why a lot of these preventative things are of value.

Bill Neumann: Agreed. It seems like the industry was getting closer to acceptance from a standpoint of people valuing dentistry with the proven oral systemic connection. I think we’re getting there, but of course with some of these government mandates … And again, I think people will look back, hindsight’s 20/20, and say things could have been done differently. Who knows? Maybe they were done exactly right.

I don’t know, but I do think that the industry needs to hammer home that oral systemic connection and look at who’s dying from COVID-19. A Lot of it is tied to diabetes and obesity. You look at the oral systemic connection and how we can maybe eliminate some of these issues through healthy hygiene and good dental practices. Hopefully, we can create some value around dentistry given that.

Dr. Dan Davidian: Absolutely.

Bill Neumann: Let’s talk a little bit … We don’t really talk much about Anutra Medical and the products that you offer, but just as a whole, Anutra and then maybe some other products out there. Talk a little bit about what type of products are we going to see dentists using in order to help patients get through this and what products are going to be used to make dentistry a little bit more efficient going forward. We talked a little bit about that same-day treatment, which is going to be something that’s going to be imperative post-COVID.

Dr. Dan Davidian: Yeah. I think we’ve kind of danced around the fact that we are going to be seeing same-day treatment and more emergencies. All of those kind of systems that we can implement that will allow us to do that more effectively are going to be hugely valuable. I’ve been preaching same-day treatment and stay with your patient for the last five years. I do a lot of CAD/CAM dentistry and I do a lot of … And I’ve changed my anesthetic protocol.

Being with Anutra Medical, being the founder of Anutra Medical, obviously, all of that kind of stemmed from our anesthetic protocol. I always preach that our systems of bouncing around between patients are developed around the inadequacies of traditional local anesthetics because the body has to kind of bring those up to a physiologic pH before they work. We have to wait 10 or 15 minutes.

Now with things like buffered anesthetic, we can sit down with a patient, we can get them numb. We can keep our same PPE on. We can have a conversation with them. Even for a lower mandibular block, I’m able to get a patient numb within two to three minutes. Many times if I’m doing quadrant dentistry and I’m doing two fillings, after two to three minutes, I’m going to tell the patient before we get started and I’m going to be polishing a little bit because they’re expecting me to wait 15 minutes. By the time they realized I wasn’t just polishing, I was removing the entire amalgam, is usually when I’m placing that matrix band, and it’s usually about 15 or 20 minutes later.

I’ve been preaching stay with your patient for the efficiency of it because uninterrupted work is 60% more efficient. I’ve been preaching it for the fact that it’s just more convenient for the doctors and the dentists. Now that we’re kind of on the forefront of this COVID thing and really having to kind of look at point contact and how many points of exposure these patients are getting from a doctor moving around and how much PPE and conservation of PPE we’re going to be using, it makes tremendous sense at this point to really evaluate all of our systems that are going to allow us to kind of stay with our patient.

Ironically, most doctors are reluctant to integrate technology or new technology into their practice because of the disruption that they assume it’s going to cause their practice and the time it’s going to take to kind of implement it. Honestly, now’s the time where we’re going to have some more time on our hands, and implementing these kind of procedures are going to be much more, much easier because we kind of have to disrupt our natural flow of things and find our new normal.

It’s kind of that season where we just got to reevaluate everything and look at products like Anutra too that will help our practices. Not only in the short term get through these kind of systems and the emergencies and being able to do same-day therapies, but also long-term set ourselves up for the efficiencies that’ll kind of make our practice thrive.

After not having to bounce around as much as I used to, I’m using these products that allow us to stay with our patient, I’ve shortened my hours and I have a lot more free time. If I’m finishing an appointment in 15-20 minutes, it really allows us to transition that room over, clean it the way we need to clean it, and set up and prepare for the next patient as well. It’s a good opportunity now to really focus on our personal lives and our professional lives and just find those things that will make us better as practitioners and as people as well.

Bill Neumann: Yeah, absolutely, Dr. Davidian. This has been great information, and I appreciate your time today. I think you’re 100% correct that things are going to look quite a bit different post-COVID. There are opportunities to be more efficient, opportunities to do things much more safely, and that helps out not just the patient, but the employees and the comfort level there as well. Now’s the time to really take a look at different products and offerings that can really help you provide not just the safety, but the efficiencies going forward.

Again, thanks for joining the Group Dentistry. Now Show, Dr. Davidian. Again, Dr. Davidian is the founder and medical director of Anutra Medical.

Dr. Dan Davidian: Thank you, Bill. I appreciate you having me.

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