“This pandemic is a perfect storm,” said Dr. Lisa Tyndall, an integration specialist with the Center of Excellence for Integrated Care, a program of the Foundation for Health Leadership & Innovation (FHLI).
As North Carolinians navigate COVID-19 and its various impacts, NCOHC decided to sit down with our partner program at FHLI to discuss how the pandemic poses significant mental health concerns, for patients and providers alike.
Tyndall, a licensed marriage and family therapist, said that the wide range of impacts caused by COVID-19 — from financial stress to anxiety and isolation — are serious stressors that negatively impact mental health.
“The fact that we can’t be with each other absolutely negatively impacts the coping mechanisms most people use of reaching out and spending time with friends and loved ones,” said Tyndall. “We are wired to connect, and right now we are limited in those personal, face-to-face relationships.”
For the provider community specifically, Tyndall worries that we tend to forget that they are humans, too.
“I think that we forget that the frontline providers are facing a lot of the same uncertainty that the rest of us are,” said Tyndall. “Especially for those providers who live alone or are caregivers in their personal lives. If a provider doesn’t have a support system, or if their support system is already stretched thin, it is an especially difficult time. There’s a physical as well as an emotional toll to the stress, and it builds up. Providers manage the stress of patient caregiving every day, and then still go home to manage their own households, potentially adding an additional layer of stress.”
“As doctors, we are trained to be the rock,” said Dr. Zachary Brian, NCOHC’s director. “We’re trained to be the provider, there to serve the community, sometimes at the expense of our own physical and mental health.”
Both Tyndall and Brian described a juggling act for providers, balancing service to their communities, personal and family safety, as well as financial well-being.
“It can feel as though you are navigating a sea of conflicting resources, literature, and research to determine the safest way to move forward with your practice,” said Brian. “Given that this is a novel virus, it is not uncommon to see this type of response. The issue arises in that there’s no one clear authority to look to for guidance, which makes informed decisions on behalf of your patients and staff ever more challenging.”
As health experts learned more about the novel COVID-19 virus in recent months, guidance from the American Dental Association, the Centers for Disease Control and Prevention, and other state and national regulatory bodies were released, but were not always in exact agreement with one another.
“The resources for providers that we have seen, although very helpful, have not necessarily always been in parallel,” said Brian. “This has created a surge in confusion.”
What can you do about the uncertainty?
Dr. Brian says, “While the provider community as a whole may be very isolated during this time, forced to make decisions with so many unknowns, there is support within your regional communities. Don’t be afraid to reach out to your colleagues. People need to be very open and transparent, so we don’t have to navigate this crisis in a vacuum.”
Dr. Tyndall says, “We have to lift ourselves up and we have to lift each other up. We don’t have to talk about it all the time, but we also should give a voice to it and not minimize the stress. It is important to have outlets to express uncertainties, fears, and concerns.”
Dr. Tyndall also shared a couple of resources for providers who need help managing their own mental health needs during this time.
The Hope for NC Helpline is a free helpline for people who need assistance coping and maintaining resilience during COVID-19. The number for the 24-hour helpline is 855-587-3463.
For first responders, the University of Minnesota, the Minnesota Department of Health, and the University of Minnesota College of Education and Human Development have released a First Responder Toolkit to help those deployed in emergency response maintain their own physical, emotional, and social well-being. The app can be accessed here (note: a login is required).
Financial uncertainty is another stressor impacting many oral health care providers. This is especially salient in the private sector, where most dental practices are small businesses. On top of figuring out how to keep everyone safe and healthy, while still providing necessary care to the community, providers must also navigate out how to stay above water financially.
“Even though it seems like practices would be bustling during a health crisis, we also know that there is a side where providers aren’t seeing as many patients,” said Tyndall. “So that financial stress — especially for smaller practices, rural practices — is very real.”
Brian said that the oral health profession is on the low patient volume side of the equation. Largely due to the use of aerosolizing instruments, dentists, and hygienists in particular, are near the top of the list of most at-risk professions for COVID-19 transmission. In response to the elevated risk, most dental offices have only seen patients for urgent needs during the pandemic.
Brian said that in the oral health care space, safety net practices are facing profound and lasting financial impacts, as well. Practices that see patients regardless of their ability to pay, and who offer care on a sliding fee scale, have very thin to nonexistent margins to begin with. Nearly completely cutting off their revenue stream can be catastrophic.
What can you do to navigate financial uncertainty during COVID-19?
Dr. Brian points to the ADA’s resources for providers, especially the following the guidances:
Financial Assistance for Dental Practices from Third Party Payers
COVID-19 Coding and Billing Interim Guidance: Virtual Visits
COVID-19 Coding and Billing Interim Guidance: PPE
Financial Obligations to Staff during COVID-19
Additionally, the North Carolina Division Health Benefits has issued temporary modifications for telehealth billing, and NCOHC has launched a teledentistry fund with support from the Blue Cross and Blue Shield of North Carolina Foundation.
If your practice is a safety net provider in need of teledentistry software, please reach out to ncohcinfo@foundationhli.org for information on how to apply for funding through the NCOHC Teledentistry Fund.
Please note: The aforementioned guidance documents are only to serve as a resource, and are not necessarily founded in scientific evidence, or endorsed by NCOHC.
According to Brian, it is important for providers to be aware of oral signs and symptoms that can alert them to potential mental health needs of their patients.
“You have parafunctional habits such as clenching and grinding that can develop as a result of stress, and from this you can see detrimental effects on teeth and other oral structures, such as extensive attrition and fractured teeth,” said Brian. “I saw that a lot with my patients when they were going through stressful events in their lives. They would come in with three or four fractures in their teeth, sometimes where the fractures extended past the gumline requiring surgical interventions.”
Brian also said that dietary changes due to stress and anxiety can negatively impact oral health. Increased sugary food and carbohydrate intake, as well as alcohol consumption, can both increase risk of tooth decay and gum disease.
“One thing that we’re not talking about enough is that we’re only seeing emergency patients right now,” said Brian. “There are people who are delaying appointments or not seeking care, and by the time they come in, what could have been a simple filling previously has now advanced to the point where it requires a root canal or an extraction. This is also particularly important for routine oral and pharyngeal cancer screenings.”
How can an oral health provider look out for mental health strains in patients?
Dr. Brian says, “Look for attrition patterns from clenching and grinding, fractured teeth, and TMJ pain.”
“As an oral health professional, having a relationship with someone in the mental health space is vitally important, also. You need to have a sounding board to discuss mental health concerns of your patients, and a trusted referral source to help route that patient to proper care.”
“It is crucially important that you have deeper conversations with your patients. Make sure that you take a whole-person care approach by including the mental health of your patients into the patient experience.”
Both Tyndall and Brian agreed that taking time to reflect and take care of yourself is incredibly important for providers during this pandemic. Taking steps to interact with family, friends, and colleagues is an important way to cope with the isolation and stress we all are experiencing.
“Dig deep into your resource and faith buckets, and be kind to yourselves,” said Tyndall. “Take time to make sure that you’re taking care of yourself, too.”
“This too shall pass,” said Brian. “Dentistry remains a profession that allows us to impact our patients in direct ways, see immediate results, and change lives. That doesn’t change with the pandemic.”
