FEATURES Overcoming Pandemic Challenges

FEATURES Moving Forward in a Pandemic

Brandonn Perry

M Dentistry magazine reported in the spring/summer online edition about how the arrival of the pandemic in March was met with fast action, long hours and creative solutions that kept students engaged in online learning and patients receiving emergency treatment. Over the last eight months, students and patients have returned to the school, though the daily routines are still far from the previous norms. M Dentistry asked six people with widely varying jobs – and with half a year of hindsight – to briefly reflect on how the school has kept moving forward.

Brandonn Perry: Safety first

As Infection Prevention and Compliance Officer at the dental school, Brandonn Perry was accustomed to developing, communicating and enforcing infection control procedures. But the challenge in the first days of the pandemic was that no one – not even state and national health agencies – knew how to best defend against this new coronavirus for the general public, let alone a dental school. Perry and school leadership had to immediately take steps that would keep students, faculty, staff and patients safe so that solving myriad other problems could go forward. Perry worked with the school’s COVID-19 Response Group that was quickly formed, as well as the existing Infection Prevention and Safety Committee he chairs. He joined a constant stream of meetings – daily, weekly, impromptu – with administrators, faculty, department chairs and staff leaders of various offices whenever input and consensus was needed. He constantly monitored outside sources, including the Centers for Disease Control and Prevention; the Michigan Department of Health; the U-M Environmental Health and Safety Department; state and federal occupational safety and health agencies; other dental schools, including six he met with weekly; and the U-M health system, including its Occupational Health Services. Perry navigated through countless online bulletins, advisories and webinars from state and national health agencies, including the Organization for Safety Asepsis and Prevention (OSAP), an industry group that advocates for the safe and infection-free delivery of oral healthcare. “In the beginning, there was little scientific evidence on anything for COVID-19 because it was new, so you were just going off of best guesses and what seemed about right,” Perry said. “And you may err on the side of being too strict because we need to stay safe. And sometimes, people thought, ‘Well, this is ridiculous.’ And it may be, but we’ll just see how it goes and we may be able to make an adjustment if necessary.” “Dentists had never worn N95 masks and typically face shields or surgical gowns were not required. So we had to figure out what was reasonable.” The strictest Personal Protection Equipment (PPE) requirement was implemented for faculty and students treating patients with high-speed instruments that generate airborne particles.

They must wear head covers, N95 masks, safety glasses, face shields, surgical gowns and foot covers. Early on, and even today, PPE was not widely available, which was another issue. Perry also participated in decisions about restricting access to the building, temperature checks for everyone who entered the building, disinfecting commonly touched surfaces throughout the building, legal compliance and human resources issues that arose, and how to communicate constantly to the wider school community about the latest and constantly changing regulations. Perry applauds the team effort from everyone, including patients, who were at times frustrated by new safety protocols. “It was this constant education and re-education of people, including patients who often didn’t understand the reason for the changes. I liked to tell them: This is the safest visit for you,” he said. “I love my job, I really do. I love helping keep people safe. You do what you have to do. It’s a sense of duty, but it’s just the right thing to do.”

Dr. Berna Saglik: Always learning

Faculty member Dr. Berna Saglik says the pandemic has been difficult, particularly in the first few weeks, but over time a significant number of positive developments have emerged that will strengthen the dental school moving forward. Saglik, a Clinical Associate Professor of Dentistry in the Department of Biologic and Materials Sciences & Prosthodontics, cited the extensive collaboration within the school when the curriculum needed to be moved online after students left campus. Faculty, curriculum administrators and educational services staff worked closely to reconfigure coursework virtually to replace in-person lectures. “I feel like we are more connected than ever,” she said. Saglik is a prosthodontist who teaches residents in the graduate pros clinic and co-directs the Dental Post-Graduate Program, where internationally-trained dentists observe faculty and grad students in clinic. She also directs the removable partial dentures course for second-year DDS students. To replace the in-clinic, hands-on experience that the pandemic interrupted for the graduate and post-graduate dentists, Saglik and her prosthodontics faculty colleagues participated in a series of seminars that quickly became popular. “Most, if not all, of the prosthodontic programs across the country participated in the seminars, sometimes two a day from different program faculty. It was almost like the national pros community having an annual meeting every single day and our residents got to see what’s happening in other programs. And other programs got to see what we were doing here.” Another major plus was advancing the use of digital imaging, which was a vital part of the virtual learning since students couldn’t have hands-on experience with full or partial dentures in clinic. Saglik credits Dr. Gustavo Mendonca and other faculty members who are part of a digital initiative that was already underway at the school. When three graduating DDS students still needed to finish their removable partial denture (RPD) requirements, but had no access to patients in-person, Saglik and her colleagues created a two-part virtual solution. Students first studied online learning modules, then demonstrated competency by successfully delivering 3D-printed RPDs to a typodont in a clinic setting. Saglik joined first author Dr. Sabrina Garcia Hammaker and colleagues in documenting the innovative educational method in the Journal of Dental Education. “Looking forward, what I’m trying to do is think of the things I would want to keep from what I’ve learned from this time, such as the collaboration across programs at other dental schools, our own collaboration at the school, and utilizing more digital dentistry,” Saglik said. “The need to try new learning methods really accelerated our digital progress. I think that should be our focus – training all of our faculty – its’s an area that we all have to learn, because these are new tools. We’re not going to be learning new foundational concepts, but we are going to be learning how to use these tools. That’s going to be a lot of learning for us all, and I think collaboration is going to be the key.”

Bliss Ledford: Empathy for patients

Bliss Ledford, a Patient Business Associate in the Graduate General Dentistry Clinic, normally talks with patients about their dental needs, cost of services, insurance coverage, scheduling and other general concerns. Once the dental school reduced patient care to only emergencies, her duties quickly morphed into calling patients to relay the news that their upcoming appointment was canceled because of the pandemic. The staff then devised a screening system to determine which patients could wait for care and which had serious problems that needed immediate care in one of the school’s clinics that were handling emergency cases. The next challenge was how to track all of the appointments that were canceled; it was March and the schedule was mostly filled out through June. It amounted to thousands of calls for the staff. It was frustrating and disconcerting for patients. “I think the most important part is to remember that each of us has been in a situation where we were in pain or uncomfortable,” Ledford said. “If we can draw on our own feelings about what that’s like, then it’s a lot easier

to understand where patients are coming from. And each patient is a unique individual person that’s calling with pain or a problem, so we really need to listen and see what that problem is and try to help them understand that there may be a light at the end of the tunnel that is not a train. And that we will get to them and help them.” During the early days and even as patient care began to ramp up again in June, each day was filled with problems that the team needed to solve. Like the rest of the world, because the staff was working from home, Zoom meetings became the answer, not just for strictly business but also for staff camaraderie. “It was helpful because it at least put our faces next to each other when we can’t be face to face in contact with someone who is part of our team. We spend a lot more time with the people we work with than we do at home. So these people have become very important to me and I really want to make sure they are OK. It’s hard to do that when we are not face to face. So we Zoom.” Although the pandemic was disruptive, Ledford found many positives. “Anytime we have a challenge, we have the opportunity to grow and change and reach new parts of ourselves that we didn’t know existed,” she said. “I think a lot of us are working on that. Resilience, determination – all of those things. You’ve just got to push through because there’s not really a normal to go back to. There’s a forward where we have to innovate, work together and figure out how to meet this challenge. That’s what we do. We’re humans.”

Dr. Patty Doerr: The neccessity of staying open

For Dr. Patty Doerr, the challenge of directing the Patient Admitting and Emergency Services Clinic, or PAES, was how to determine which patients had the most serious emergencies and which could be delayed. Instead of in-person screening, it was done mostly by phone by faculty and staff who were working from home as the dental school went into its pandemic protocols. “One of the biggest priorities the first week was how do I get my dentists in PAES set up at home so they can still manage patients. Normally, we would have scheduled patients to come in to the clinic, but we had to do more triage by phone, calling in prescriptions, working with their health providers to make sure that their symptoms were managed until we could get them in here. Initially, we had a much-reduced capacity for the number of patients that could be seen by PAES, oral surgery, endodontics and pediatrics, so we had to work with those clinics on how we were going to do this.” Technical support from Dental Informatics was crucial in helping staff work from home. Then Doerr had to make sure there were dentists and dental assistants scheduled in the clinic for patients who were coming in for treatment. Full-time faculty, adjuncts and other staffers, often from other clinics or who would have been working in pre-doc clinics with DDS students, volunteered to help in PAES. A sense of teamwork and camaraderie developed across the school. “The first two or three weeks, you never could really relax. It was always: Oh, I didn’t think of that. It was very fluid, but people were willing to help in any way possible. ‘What needs to be done?’ It was outside of their normal duties. With most folks you saw the best of them, even though it was the craziest time.” “I met a lot of people who I had never met before. I probably have half of the school in my cell phone contact list now. We communicated by text because you didn’t know where people were, so you couldn’t go to their office. You weren’t sure if they would check their email by the time when you needed the answer because things had to be decided very quickly.” “I’ve said a couple of times over the summer that necessity is the mother of invention. We’ve certainly reinvented a lot. It’s taught us that we are all very much interdependent on each other, maybe more than we realized. We need each other more now than we ever did. It brought out a lot of frustration in the circumstances, but for the most part you saw people really work together and keep the mission going of seeing the patients and getting the students back in here. We stayed open, we had to start over and we’ve only gone up from there.”

Probably the most commonly used word at the dental school since March is “remote” – as in “remote access” or “remote user.” Whether it is students accessing lectures, or staff accessing patient records, or faculty and students accessing digital radiology images, the ability to securely enter the school computer network “remotely” is imperative to navigating the pandemic protocols. The team behind those connections is led by Matt Vuocolo, Information Technology Operations Manager in Dental Informatics. He opens any discussion of the pandemic response by listing his team: Systems administrators Austin Bruck, Mike Crisovan and Phil Kennedy. “They are vital. None of this could have been done without them,” Vuocolo said. “All I ever did was help organize and orchestrate and identify problems. They solved them.” Reconfiguring parts of the school’s technology network and infrastructure was an immediate priority filled with problems. While a significant number of the dental school community, about 125 people, had remote access before the pandemic, most had been brought into the system over time with benefit of unrushed installation and training. When the pandemic arrived, seemingly everyone at the school – it turned out to be about 850 more people – needed to be outfitted with remote access, immediately. Many use Windows and others use Apple computers. Not every user’s software was the same or up-to-date. Employees range from tech-savvy, do-it-yourself users who could quickly follow connection directions to tech-challenged users who would need to be walked through changes step-by-step, even for basics like installing Zoom. Vuocolo credits Business Systems Analysts Lisa Newton and Usha Dronamraju who helped with scheduling and education for the users of the newly expanded remote system. Then there is the complicated network of computers and servers within the dental school that had to be configured to accept the remote queries. Two platforms in particular were crucial. Staff, students and faculty all need access to Axium, the patient portal that contains health records, appointment schedules and billing information. The other is called MiPacs, which provides students and faculty with access to digital imaging of patients. To support the new remote load, system administrators built out a new virtual computing environment and changed the roles of existing computers at the school, increasing the number of computers from 35 to 132. As the pandemic progressed, staff and faculty would present new problems, and Vuocolo and his team would solve them on short notice, even if they might have preferred to spend time devising a more comprehensive solution. “I think we could have been hung up by ‘paralysis by analysis’ but we had to solve the need. We’ve addressed everything and then some. I’m pleased, very pleased. I think everyone in IT is always looking for a solution. I think it’s just an IT thing – we want everything to be the best.”

Deanna Goddyn: A patient connection

For Deanna Goddyn, the move to working at home came on one of the first days the dental school sprang into action to combat the pandemic. The Patient Services Associate suddenly found herself on her way home with her computer and monitors in tow. She quickly set up her equipment on a desk in the spare room of her home in Blissfield, two miles north of the Ohio border near Toledo. She forgot to bring an ethernet cable, so that evening she bought one at the local Meijer store. “I got everything hooked up for the next day, and I’ve been here ever since,” she said. Goddyn is a prime example of the hundreds of people at the dental school, and thousands at U-M, who are following the campus pandemic mandate of “if you can do your job from home, you must.” The transition was fairly easy for Goddyn because she spends most of her day on the phone, answering questions from patients, directing them to the correct clinics and scheduling appointments. Now the phone calls ring in on her computer in Blissfield instead of in the Patient Services Office at the dental school. She handles about 100 calls a day, but it has fluctuated from a low of 55 up to 120. The calls are different now compared to the pre-pandemic days. Beginning in March, many appointments needed to be canceled as the school reduced care to emergency only. It has gradually increased the number and type of patient appointments, but protocols still limit the number available. So instead of quickly making appointments or referring callers to the correct clinic, Goddyn must now do more screening of calls and explain that things have changed. Patients who are used to immediate care or regularly scheduled appointments have often been disappointed, or angry, that they may have to wait longer to make an appointment. “It’s been difficult at times because they’re not sick, everything seems to be getting a little bit better, and they want in for an appointment now. So you just have to use a little bit of persuasion.” Working at home means Goddyn no longer shares a two-hour round-trip van pool commute to U-M with six Blissfield residents, but she misses the ability to run upstairs to a clinic to answer a question quickly. Still, she said she loves helping patients find a treatment solution at the dental school. “To do this job you need to be a people person. Even on the phone, they can tell the difference if you are not.”

Study Tracks Spread of Aerosols in Clinics

Dr. Viyan Kadhium (center) uses a dental drill on a typodont as engineering Professor Margaret Wooldridge (right) and postdoctoral scholar Mario Media record resulting aerosol spray.

Workers from U-M’s Architecture, Engineering and Construction Services install plexiglass partitions in a dental school clinic.

Early in the COVID-19 pandemic, Dr. Romesh Nalliah, associate dean for patient services at the School of Dentistry, faced many daunting questions. Among them: How many patients could the school safely treat in its multi-chair dental clinics and how could it best protect patients and providers from coronavirus during appointments? “It was March and April,” Nalliah said. “Nothing much was known about the virus. To be safe, we were seeing only four patients at a time in a 36-patient clinic. I just said, ‘We need help.’” Most of the dental school’s various clinics are large rooms where faculty and students would normally be treating from 10 to 40 patients at the same time, each in an operatory, or cubicle, surrounded by 5-foot-high panels. That space configuration poses different challenges for the safety of patients and dentists than private dental offices, where a dentist is typically seeing one or two patients at a time in separate rooms. Various types of dental instruments, such as high-speed handpieces used for drilling or cleaning teeth, generate aerosol droplets, which can contain viral particles. Research was lacking on how those droplets could travel in large clinics like those found at the dental school. Nalliah reached out to the U-M College of Engineering. He had worked before with U-M’s Center for Health Care Engineering and Patient Safety and its director, Amy Cohn. She put him in touch with Margaret Wooldridge and André Boehman, professors of mechanical engineering, who agreed to set up a study using cameras, special lighting and other equipment to track how aerosols are spread. Wooldridge, Boehman and their team of graduate students and post-doctoral fellows determined that they needed to focus on the dentists’ high-speed drilling. Drills spray water, which serves as a coolant during use. “We wanted to know specifically, where do the aerosols go?” Wooldridge said. “And what might we do to reduce the transport and fate of those aerosols?” They used highspeed imaging, low-speed imaging and aerosol sampling to determine the pattern and distance of how aerosol droplets spread. A video camera recorded as Dr. Viyan Kadhium, a dentist and Nalliah’s research assistant, wielded the drill and practiced on a typodont, which is a mannequin head with plastic teeth that simulate a patient. Wooldridge said there are so many variables in dentistry that it was impossible to determine exactly where and how far the aerosols would spread in every situation. However, she and her team gathered enough data to determine that aerosols can travel from one cubicle into an adjacent one, potentially putting a nearby patient, dental students and faculty at risk. They also determined that plexiglass barriers added to the top of the standard cubicle walls can stop the particles. “I was surprised at how variable the aerosols are that are generated by the dentist,” Wooldridge said. “I expected them to be more systematic and well-behaved, but they’re very erratic. They’re like a toddler at Meijer. In the candy aisle maybe.” Among the factors that can affect dispersion of aerosols are which tooth and tooth surface the dentist is working on, whether the dentist is left- or right-handed, the dentist’s posture and their hand position. Once he had the engineering findings, Nalliah and Mike Folk, the dental school’s building manager, consulted with Michigan Medicine airflow experts, then researched the dental school ventilation system to determine the direction that air flows through

clinics. Based on the aerosol and airflow data, plexiglass barriers were added to the top of some of the cubicle walls. It was not as simple as putting plexiglass around every cubicle because that could inhibit airflow. “Inhibited airflow means there would be a risk of stagnating, which increases the risk of transmission to subsequent patients,” Nalliah said. That means some cubicles are still going unused, but clinics with plexiglass can now safely support about 50 percent of their capacity, an increase from the more limited number when the pandemic first arrived. The barriers were initially installed in four clinics, which increases the number of patients that can be seen around the school at one time. Some clinics may add the additional barriers later as the current plexiglass shortage eases. Nalliah said the ability to call on the expertise of researchers at the College of Engineering was invaluable. “The capacity that we have now is still limited, but much better than what we were first facing.” Given the evolving nature of the COVID-19 pandemic, more such collaboration may be necessary. “It’s an ongoing, ever-changing, dynamic situation,” Nalliah said. “And the whole world’s response to it as well as the dental profession’s response to it is everchanging. We might need Margaret and André’s help again.”

School Surveys Essential Workers on COVID-19, Tests for Antibodies

A survey of nearly a thousand people who were tested for COVID-19 antibodies at the School of Dentistry this summer examined how the pandemic is affecting the life experiences of essential workers, including dentists. The study, “Impact of COVID-19 on Life Experiences of Essential Workers Attending a Dental Testing Facility,” was posted in September on the website of JDR Clinical and Translational Research in advance of being published in the January 2021 print issue of the journal. Researchers analyzed surveys completed online by 984 people tested for antibodies during May and June. The tests were for asymptomatic essential workers in three categories – those who work in dentistry, those in other healthcare fields and those in nonhealthcare fields, including first-responders such as police and fire personnel. In addition to determining that only 21 people tested positive for antibodies, valuable information was gathered from surveys taken by the testing participants. “Our findings support that dental workers are as vulnerable as other essential workers to the psychological impacts of COVID-19, and that testing may help alleviate stress and anxiety associated with these pandemics,” said Dr. Margherita Fontana, lead author and the Clifford T. Nelson Endowed Professor of Dentistry in the Department of Cariology, Restorative Sciences and Endodontics. “The study also supports the acceptability and satisfaction of testing done in a dental setting, highlighting a role that dentistry can play within the healthcare system by helping with testing and other surveillance methods during a pandemic.” Researchers found that dental providers reported being less afraid of COVID-19 than

A participant in the School of Dentistry’s COVID-19 antibody tests waits for blood to be drawn with a finger prick during testing this summer. Participants also completed an online survey.

the other two essential worker groups. “That may be because we have long been attentive to employing procedures and personal protective equipment to safely provide care in the high-risk environments we work in,” Fontana said. Additional survey findings include: • More than 90 percent of respondents said they always or frequently engaged in preventive measures, such as wearing masks. • More than 80 percent said a COVID-19 test received in a dental setting is acceptable, that they were “definitely” satisfied and would “definitely” recommend it to a friend, family or coworker. • More than 70 percent were sometimes, frequently or always worried about their friends and loved ones contracting

COVID-19 and of resulting financial problems. • For all groups, more than half of the respondents stated that the pandemic had a negative (somewhat worse or worse) impact on daily life (59 percent), interactions with others (65 percent), stress levels (66 percent), and enjoyment of life (56 percent). • More than half of the respondents stated that the pandemic had a positive impact (same, somewhat better, or much better) on caring about one another, self-care and exercise. • More than two-thirds of respondents said knowing the results of an antibody test would decrease their level of stress and anxiety. Dr. Robert Eber, Clinical Professor in the Department of Periodontics and Oral Medicine and Director of Clinical Research, led a team of faculty members and staff who developed and administered the antibody testing. Other co-authors of the resulting study in addition to Fontana and Eber are Dean Laurie McCauley; Dr. Mark Fitzgerald, Associate Dean for CommunityBased Collaborative Care and Education and an associate professor in CRSE; Emily Yanca, research project manager in CRSE; and George Eckert, Department of Biostatistics, Schools of Medicine and Public Health, Indiana University.