From Cavities to Stress-Grinding, the Pandemic Has Been Hell on Our Teeth

Dentistry during COVID-19 has been a challenge for patients and practitioners alike. Illustration by Wren McDonald

On March 26th, at the start of the first pandemic shutdown, Montgomery County resident Cathy Belfield was working from home while her two kids played in the driveway, rolling around on skateboards.

While skateboarding isn’t a typical activity for her son, who is “extremely cautious,” it was a nice day outside, and without anywhere to go, he “needed some kind of outlet,” Belfield explains.

Then the screaming started.

Belfield’s son, Andrew, who was 11 at the time, had face-planted in the driveway, breaking off one permanent front tooth and shoving the other up into his gums. His nerves were exposed, and it was clear he needed emergency attention.

One problem: Belfield’s usual dentist wasn’t open. On March 22nd, Governor Tom Wolf had enacted new COVID restrictions that barred dentists from providing emergency care outside of negative-pressure rooms and without N-95 masks. According to the president of the Pennsylvania Dental Association, no dental facility in the entire state possessed a negative-pressure space in which to operate. Patients had nowhere to go but the emergency room — which, due to coronavirus, they were being told to avoid at all costs.

“We were in complete panic,” says Belfield. “We thought maybe he would just completely lose his two front teeth.”

Poor Andrew is just one example of the many ways a hellish year was hell on our teeth. Dentists have seen broken braces, gaping cavities, and teeth knocked clean out of heads. Not to mention the whole domino trail of issues that stem from a lack of access to regular care and maintenance on a community-wide level — an issue that’s compounded for those without insurance. The list goes on and on.

A study published by the Centers for Disease Control and Prevention called 2020 a “perfect storm” in oral health. Even in normal times, dentistry has long had a problem with patients who struggle to consistently access care. “There has always been a storm challenging our oral health,” says Rittenhouse dentist Joseph Roberts. “COVID just turned it up to a Category 5.”

While most dental offices are back in business (albeit seeing fewer patients due to limited capacity and never-ending rounds of sanitizing), 2020 was an uphill battle for practices and patients alike. So how bad was the past year on our teeth, and how do we bite back?

For Regina Thomas-Salley, it started in November with a toothache. Thomas-Salley, a resident of Lincoln University in Chester County, contacted her dentist, who was quickly able to discern that a root canal she’d had done some 20 years ago, right out of college, needed repairing. Simple enough. But then searing pain started on the opposite side of her mouth. It was so bad she could barely lift her head from the pillow in the morning — so wrenching that if she tapped her jaw on the right side of her face, pain radiated through her inner ear.

She thought she had an ear infection. But her dentist told her the raging pain had nothing to do with the root canal or an infection of any kind. The culprit? Teeth-grinding. The anxiety of months spent working her high-stress banking job from home alongside her husband and three homebound college-student children — not to mention the whole living-through-a-global-health-crisis thing — was manifesting through the gnashing of her teeth.

Stress has been one of the hallmarks of the pandemic. “People dissipate stress in different ways. Some people get GI ulcers. Some people get migraines. Other people grind and clench their teeth,” says orthodontist Kellyn Hodges.

The negative side effects of grinding through tension are many; for Thomas-Salley, it led to temporomandibular joint (or TMJ) disorder, which can cause intense pain and sometimes lead to a locked jaw. And because the myofascial muscles are some of the strongest muscles in the body, Hodges explains, “This grinding habit can literally fracture teeth — it can fracture cusps off, and it can send a fracture line straight down the middle of teeth.”

Thomas-Salley is far from the only one of us who’s been working out her stress on her teeth. A Manhattan prosthodontist shared with the New York Times that she was seeing more cracked teeth in her practice than ever before — at least once a day since she returned to the office in June. Dentists say the trend holds true in the Philly region as well. Hanh Bui Keating, a periodontist in Bryn Mawr, has seen at least a 50 percent uptick in patients coming in with cracked teeth. “Some days, cracked teeth is all I do,” she says.

Bala Cynwyd endodontist Eric Hodges, Kellyn Hodges’s husband, says the rise in cracked teeth has thrown off his schedule. One day in November, he had six back-to-back root canals in his appointment book, four of which had to be canceled once he realized those patients had fractured teeth that couldn’t be salvaged. And it’s not just teeth that are cracking: Kellyn Hodges says all the teeth-grinding is leading to more broken braces, appliances and wires as well.

“This is an unprecedented amount of breakage,” she explains. “In the past, on a normal day, we might have had a rate of 30 percent of people coming in with breakage. We are now at a rate of 60 to 70 percent of patients who walk through the door with some kind of breakage.”

While no one wants broken teeth, other issues can stem from these rifts, even when they’re minuscule. Tiny cracks — Bui Keating likens them to the hairline fractures you sometimes see on eggs at the grocery store — may not seem significant at first, but they can allow bacteria into a tooth, leading to infections.

“Most of the time, there’s no pain, believe it or not,” notes Bui Keating. She recommends seeing a specialist if patients notice bleeding, pus, a bad taste, or small pimples on the gums, which can be signs of a deeper infection. “Sometimes it can be an overreaction, but we’d rather find the problems earlier than not.” While these symptoms may come and go, a bad infection can erode the jawbone if left untreated. That requires extensive (and expensive) restructuring.

For those who have found themselves grinding their way through the pandemic, it’s not too late to prevent further harm. Dentists recommend investing in a night guard — a fitted retainer-like appliance made of thick plastic that can take a lot of wear and tear. Kellyn Hodges makes her mother a new one every year, as she tends to grind straight through them (better the plastic than her molars). While you can find generic mouth guards online, Bui Keating strongly recommends that patients get something custom-made by their dentist: “When it’s not fitted right, it can cause more stress in your jaw. When we fit it, we make sure it distributes the force evenly. That’s how it’s protecting your teeth.”

Night guards can also reduce the strain on the jaw for those suffering from TMJ disorder. Thomas-Salley says her dentist gave her a bite plate — an acrylic appliance that fits over the teeth — to sleep in; she can detect a difference in the pain after nights when she wears it vs. those when she forgets. She’ll pop it in as well when things get tense during the day: “At stressful times, I find myself biting down hard and grinding on my teeth. When I find that happening, I go and put the bite plate on.”

Grinding is a slow and steady way to destroy teeth, but dentists have also seen increases in much more instantaneous, brutal methods. It turns out being bored at home can be a recipe for a lot of dangerous high jinks. “I’m on staff at Abington Hospital, and we saw a lot of trauma over the summer, both adult and pediatric,” says Angela Stout, a pediatric dentist in Erdenheim. With no school — and with sports practices and extracurriculars canceled — kids had less structured time and more pent-up energy to get out. That meant a lot of knocked-out teeth.

It was Stout who answered the call — or, rather, the text — when Andrew Belfield smashed his teeth while skateboarding. As Cathy Belfield was trying to find a dentist in New Jersey who would see her son, her brother texted Stout, his family dentist.

Luckily, while Stout was on the phone with Belfield, she got word that the state was lifting the restrictions on emergency procedures following pushback from dentists, which meant she’d be able to see Andrew the next day. And because she prompted Belfield to hunt down the tooth fragments by flashlight on the driveway and put them in water to keep them moist, Stout was able to reconstruct Andrew’s shattered tooth after performing root canals on both front teeth.

“We saw a lot of trauma over the summer, both adult and pediatric,” says Angela Stout, a pediatric dentist in Erdenheim. Illustration by Wren McDonald

Young Andrew’s case was an extreme one, but it serves as a gruesome reminder that dentistry is essential — and not just in emergencies. When dentists are inspecting your teeth, they’re not only checking that you brush — they’re screening for diseases and oral cancers. “Gum disease is known to be linked to diabetes and heart disease, and certain types of gum inflammation and types of smells are indicative of diabetes,” explains Kellyn Hodges. “We’re often the first professional to inquire about diabetes and send patients back to their generalists. A lot of people really don’t connect those dots, but they’re connected. There are a lot of major diseases that are detected by things in the mouth.”

Dentistry works best when patients have consistent access to care, which is another reason the past year has been so bad for our teeth. In this industry, an ounce of prevention truly is worth a pound of cure. Regular cleanings give dentists opportunities to find small issues before they become big ones. But when the pandemic closed down dentist offices along with everything else, all care — except serious emergencies — came to a screeching halt. That meant new problems weren’t caught, and already-established treatment plans were on pause for months. Even after most dental offices reopened, patients continued to postpone care. USA Today reported in the fall that 15 to 20 percent of regular dental patients said they wouldn’t reinstate their appointments until there was a vaccine or proven COVID-19 treatment.

According to Stout, this slowdown in care has led to more and worse cavities. Patients who had treatment plans for tooth decay and gum disease all the way back in January weren’t able to see her until her office reopened in June. As a result, “A lot of the decay or cavities that we were seeing that may only have required a simple filling ended up being a root canal and crown,” she says.

The pandemic shutdown also disrupted our set schedules, which contributed to more problems. The dental decay Stout saw in her pediatric patients birthed a new name: “COVID teeth.” “Kids are out of school; they had no routine,” she says. “They were staying up late, eating all night, not brushing. Decay that was starting actually escalated much more quickly because of lack of typical home-care routines.”

We all know, intellectually, that we should be taking better care of our teeth. In a 2017 survey, 85 percent of Americans said oral health is “very or extremely important to their overall health.” And yet in that same survey, only 58 percent of respondents said they visit the dentist at least once a year. And that was before the pandemic! In June, the ADA projected dental spending would drop by as much as 38 percent in 2020. The group predicts that it will improve in 2021 but won’t return to pre-pandemic levels.

That decreased spending represents not just a lack of current dental care but also a risk for the future. Along with cost, people forgo dental care because of time and distance to travel to a dentist. Dental offices are primarily small businesses, and the declines in revenue — not to mention the cost of adding medical-grade air purifiers to offices to make them COVID-safe — is putting some practices out of business and pushing older dentists to retire early, according to Stout. That, in turn, “makes it harder for patients to find a dental home.”

Lack of access to dental care is worse for low-income populations and the uninsured, and it disproportionately affects Black, Hispanic and indigenous communities — which, as we know, also bore the brunt of the coronavirus pandemic. While much of the discussion about school closures this year focused on the need for laptops and access to school lunches for low-income students, dental-care programs were also disrupted. Tiffany Foy, a dental hygienist who worked with a nonprofit in Oregon that provided care to students without regard to income or insurance, told the New York Times she worries about what the cutoff of this pipeline could mean for pediatric patients: “They could have a mouthful of cavities and the parents aren’t even aware.”

Then there’s the question of whether patients feel safe going to the dentist amid a pandemic. It doesn’t help that dental workers — particularly hygienists — have, of all professions, the highest risk of contracting coronavirus, even more than nurses, paramedics, flight attendants and surgeons. (The least at risk? Loggers. Store that factoid away for the next pandemic.)

But what patients might not realize is that unlike, say, loggers, dentists have significantly more experience working safely in an epidemic. The rise of HIV/AIDS, spread via a blood-borne pathogen, changed dentistry forever, creating new universal precautions that are still in place. “We are working very close — six inches to a foot — and we’re working with blood and saliva,” says Bui Keating. “Even as dental students, we don’t come near someone unless we have a shield, mask and gown.”

Unfortunately, face shields, masks and gowns haven’t been easy to come by due to the nationwide personal protective equipment (PPE) shortage. Last spring, non-medical workers collected and donated their PPE to hospitals and frontline workers, and dental offices were among those that turned over their gear. When small dental practices were preparing to reopen a couple of months later, restocking scarce and suddenly exorbitantly expensive PPE became yet another hurdle.

“One of the biggest early challenges was sourcing, finding, and being able to trust our PPE,” says Rittenhouse’s Joseph Roberts. “My staff was petrified of being exposed.” Eric Hodges says that overhead at his practice has skyrocketed, in part due to PPE costs. The masks he once purchased for 85 cents apiece now run him $5. Some dentists have added PPE fees to help cover these new costs, though Hodges says he isn’t ready to pass them on to patients.

PPE isn’t dentistry’s only line of defense against the virus. Dental offices have invested in HEPA air filters with air ionization technology, along with UV lights to disinfect the air and surfaces, in an attempt to reduce the risk of COVID particles hanging around — though the efficacy of these measures is still unclear. And some have pivoted to tele-dentistry, triaging more patients over the phone and putting new policies in place to keep the number of people in their offices to a minimum. “We spent multiple days over weeks reviewing the data, our protocols, and our strategies to first keep the virus out of the office and then to effectively limit or eliminate the risk of transmission inside our four walls,” Roberts says.

Montgomeryville resident Steven Hill, whose two children are patients at Kellyn Hodges’s orthodontics practice, describes himself as “on the more cautious side” when it comes to the pandemic. But when he showed up wearing rubber gloves and a face mask for his kids’ first appointments after dental offices reopened in early May, he was surprised at how seamless every step of the process was and how safe he felt. He stayed in his car until the office called him up. The door was opened for him so he wouldn’t have to touch the handle, temperatures were taken, and he was handed a brand-new pen, which he kept, to fill out paperwork.

“I was really concerned about going, and I could really let that caution down because it was all taken care of for me,” says Hill. “It was just really well-thought-out.”

While the precautions have shifted over time as we’ve learned more about the virus and how it spreads, the safety measures appear to be working. The ADA released a survey of more than 2,000 dentists showing that fewer than one percent had contracted coronavirus as of June, demonstrating that dentist offices could operate safely throughout a pandemic. And thanks to a new resolution adopted by the American Dental Association’s house of delegates in October — which recognized all preventative oral care as “essential” going ­forward — it’s less likely that dentistry will see a widespread shutdown if and when such a situation recurs.

“This resolution helps to ensure that patients have access to a full range of dental care whenever they need it in the current pandemic or other future crises,” said ADA president Daniel J. Klemmedson.

There’s been a lot of talk this year about how experiencing a global pandemic is ramping up our be-ready-for-anything instincts. We’ve spent an entire year stocking up on canned goods and toilet paper and learning to bake bread. But it’s clear by now that those survival instincts should also include staying up on teeth-cleanings and cavity-fillings — just in case.

Published as “The Dentist Will See You Now” in the March 2021 issue of Philadelphia magazine.