Dentists and dental clinics in Indonesia are attempting to minimize the high risks they face amid the COVID-19 pandemic by embracing telemedicine and tighter health protocols in order to continue treating patients and to keep their businesses afloat.

Dental procedures frequently generate formations of droplets and fine water particles in the air that can carry the novel coronavirus that causes COVID-19, which may end up on the clothes of, or be inhaled by, both dental healthcare personnel and patients.

Read also: Indonesian dentists walk on tightrope as practices forced to close due to COVID-19

The Indonesian Dentists Association (PDGI) has advised the public not to see dentists unless for emergency or serious dental problems, such as oral bleeding or severe dental pain during the COVID-19 pandemic. In April, the PDGI reported that six dentists had died of COVID-19 after treating patients.

“Patients can understand their degrees of urgency by consulting the dentists virtually. It has never been more obvious that dental organizations must embrace teledentistry,” PDGI chair Sri Hananto Seno told The Jakarta Post on Thursday.

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Many patients, including Intan Kurnia Marka, have decided to postpone going to the dentist. Intan, herself a 24-year-old dental student in Yogyakarta, has skipped her routine braces checkups during the outbreak. "A loose bracket is a common problem for people with braces but it doesn't need emergency care. I fear the COVID-19 transmission more," she said.

Hananto said that patients nowadays might want to communicate with dentists online, especially if their dentists have established good relationships with them. Hananto, for example, asks his patients to take several pictures of their mouth and send them through WhatsApp so he can analyze the problem.

“This is the closest we can get to solving the dilemma of whether to continue to work and keep earning or to reduce the risk of COVID-19 transmission,” he said, adding that in outbreak epicenter Jakarta, the COVID-19 situation had prompted nearly 70 percent of dentists to stop practicing and lose their source of income.

Hananto said the PDGI, which has 272 branches across the country, was also starting to collaborate with telemedicine apps such as Klikdokter and Halodoc so that dentists could register easily.

Limited services

Dentistry, however, has yet to settle on an established new normal. Dentists and clinics are still grappling with how best to serve needy patients and the results are either a limited service or a costly one.

Artist Yustiansyah Lesmana told the Post that his wife, whose gums had swollen, went to RE Martadinata Dental Naval Hospital in Central Jakarta on May 8 where she was asked to cover the cost of personal protective equipment (PPE) for the medical workers in order to obtain emergency treatment. They did not use the national healthcare system BPJS Kesehatan because that system requires the patient to go see their nearest dentist first before being treated as a dental emergency in the hospital.

“My wife was expected to pay Rp 500,000 [US$ 33.50] outside the treatment fees. We declined to see the dentist eventually,” he said. The couple spent hours, calling several dentists and clinics, to find a dentist that could treat Yustiansyah’s wife’s problem. Finally, they went to the University of Indonesia clinic in Salemba, where she left her number and was called and treated remotely by a dentist because the dental clinic was closed to visitors.

RE Martadinata Dental Naval Hospital head Col. Agus Gamal Mulya said the policy of patients buying PPE for dentists applied to general patients, to partially cover the cost of PPE given the scarcity of protective gear in the first weeks of the outbreak and subsequent skyrocketing prices.

“We needed to procure protective gear but were unable to do it without aid from other parties. A set of PPE cost around Rp 500,000 per staff member. Meanwhile, a patient with an emergency case is treated by two personnel, a doctor and a dental assistant. We decided to charge the patient for the PPE at half the cost if they agreed,” Agus told the Post on Tuesday.

He added that the policy did not apply to patients covered by the Health Care and Social Security Agency (BPJS Kesehatan).

Atika Nurmalia was also only able to obtain a limited dental service recently. Unable to bear the incessant pain from her swollen gums, the 24-year-old woman from Kudus regency in Central Java, decided to see a dentist, despite her fear of contracting COVID-19.

When she visited the clinic, she went through a body temperature check and was told to maintain physical distance. However, she was surprised when she saw the dentist only wore a surgical mask and did not examine her mouth at all.

“I was not told to open my mouth, I didn’t even remove my mask. I understand that must be dangerous to do especially as the dentist only wore a mask but what’s the point then of visiting the dentist?” she said. Her experience demonstrated the necessary shift in dental practice as some procedures may be now carried out without visiting a hospital or clinic.

Tighter protocols

Endodontist Rio Suryantoro, who owns a clinic in Tebet, South Jakarta, said he had been conducting assessments regarding COVID-19 through WhatsApp as a routine procedure.

“If a patient needs emergency care, we must first assess their condition and travel history in the last 14 days before agreeing to an arrangement. Meanwhile, all kinds of nonemergency practices should be postponed,” he told the Post.

Rio added that even with such precheck measures, the risks were still high as long as the patients were not tested for COVID-19, especially as some COVID-19 patients could be showing no symptoms.

“Now is a good time for dental professionals to learn about and improve infection control. All this time, both dental patients and staff could be exposed to various viruses and bacteria through direct or indirect contact with fluids, but even the standard precautions are often overlooked,” said Rio.

The standard precautions in dental practices include hand hygiene, use of PPE such as gloves, masks and eyewear, safe injection practices, sterile instruments and a clean and disinfected environment.

In the future, patients may expect to see all dental staff wearing gowns, masks, face shields, gloves and boots. Hananto of the PDGI said this protective gear was an absolute condition for any dentists who wanted to work during this pandemic.

Hananto added, however, that not all dental healthcare personnel could afford protective gear. The PDGI has received 5,000 PPE items from the National Disaster Mitigation Agency (BNPB) and distributed them to several regions. This amount is far from enough to cover all 34,000 dentists across the country, according to Hananto.

“Without an effective vaccine, the pandemic will last but we can’t stop working forever. The way to work is by wearing full protective gear,” he said.