Alaska doctors and dentists can resume knee surgeries and fillings starting Monday. Will they?

Around Alaska, elective oral and medical procedures are allowed to resume starting Monday — if patients test negative for COVID-19 within 48 hours before undergoing procedures that could spread the virus.

Alaska’s doctors and dentists halted all but urgent or emergency procedures in March under state COVID-19 protections meant to protect them and their patients.

Since then, plummeting admissions have plagued the state’s hospitals and nursing homes. A statewide association estimates at least $282.8 million in lost revenue through June.

Still, despite growing financial pressure, many providers say they don’t expect things to return to normal for weeks, if ever.

Dental organizations say the testing turnaround window is so restrictive that they won’t be able to meet it by Monday. Instead, they’re working with the state to come up with a plan.

Rural doctors and dentists face even more hurdles trying to get patients tested in time given limited testing capacity and the sudden departure of the state’s largest regional air carrier, when RavnAir Group announced bankruptcy last month.

Dillingham actually has a hospital, unlike many more rural areas, but it has limited tests available for the whole community, dental hygienist Brittany Dschaak said Wednesday during a meeting of the state board of dental examiners.

“They’re not going to release a test for us to use on a patient that’s asymptomatic, especially with the fishing season that’s starting,” Dschaak said. “To do a 48-hour turnaround from a rural area is nearly impossible with canceled flights and weather.”

Slow start

Under a state health mandate issued in mid-April, the state begins allowing surgeries and intensive procedures “if delay is deemed to cause significant impact on health, livelihood, or quality of life.” The mandate requires a plan to reduce or stop procedures if a surge or resurgence of COVID-19 occurs or if there’s a shortage of personal protective equipment.

Any patients undergoing procedures such as intubations that could “aerosolize” the virus must get tested in that 48-hour window.

The facility also needs to have enough capacity to accommodate an increase in both COVID-19 and more post-procedure hospitalizations.

Hospitals aren’t expecting a flood of procedures to start this week, said Jared Kosin, president and CEO of the Alaska State Hospital and Nursing Home Association.

“To start doing procedures like this, they will only do so if it is safe to do so,” Kosin said. "When things open up on Monday, I expect it’s going to be a gradual process.”

[Alaska is reopening for business, but widespread COVID-19 testing remains unavailable]

Many larger hospitals have rapid testing available. But other facilities have to rely on getting a courier to run the sample to a state lab and then get the results back, he said. “That absolutely can run past the 48 hours. That’s a limiting factor.”

Alaska’s chief medical officer, Dr. Anne Zink, acknowledges that the state doesn’t have enough tests for the entire medical and dental community.

“Do I think there’s enough capacity May 4 for every single area in the state to do elective procedures? No,” Zink said last week.

The state is working with providers to prioritize patients who need tests first, she said this week. Any clinic and provider can set up a process to get testing swabs and send them to labs, she said. The state is also working with pharmacies to boost testing capacity.

“We really are asking providers to do the right thing for their patients,” Zink said Friday. “But we’re trying to add an additional layer to make sure that they were protected and their patients were protected.”

‘Next to impossible’

The state’s 48-hour test requirement puts an extra burden on dentists, they say. Many patients may have to wait past Monday.

About 85% of what they do produces aerosols, according to David Nielson, chairman of the Alaska Board of Dental Examiners.

“We knew as dentists that that was going to be pretty much next to impossible to comply with,” Nielson said.

Emergency appointments can proceed, as can basic cleanings that don’t produce aerosols, but Nielson said that leaves a lot of procedures lingering that might later become emergencies.

“Dentistry has always been about prevention,” Nielson said.

On Wednesday, the board of dental examiners met with Zink to clarify the mandate and seek a compromise.

[Free pop-up COVID-19 testing near Talkeetna is Alaska’s first — but not the last]

Oral health is critical in Alaska, Zink said, and it’s a challenge to “normalize this new normal of COVID,” particularly when it comes to the microdroplets that spread the virus. People may be most contagious before they show symptoms of the illness.

“The test is a tool that is being utilized more and more given the fact that screening just based on symptoms is increasingly challenging to identify COVID patients,” Zink said.

Emergency and urgent dental procedures can still go ahead, Zink said.

“We're trying to find a path forward that keeps you safe for the more elective things,” Zink said.

Members of the board, the state’s health department and the Alaska Dental Society formed a committee to talk about solutions in re-opening dentistry and a possible mandate that relates specifically to dental care.

“The goal is to make some compromises or find some common ground so that more routine, non-emergency dental work can be started,” Nielson said.

Besides some of the basic cleaning and some orthodontic work, “everybody else is sort of in a holding pattern,” said David Logan, executive director of the Alaska Dental Society.

Statewide bottleneck

At Orthopedic Physicians Alaska, a large, busy practice in Anchorage, Dr. Eli Powell says there is a backlog of 500 patients. The practice is using hospitals to test patients in the 48-hour window.

Powell, who serves as president of the state medical association, is performing knee, hip and shoulder surgeries next week. He expects to work the weekend.

Even with that busy schedule, the practice will be at about half the normal volume, Powell said. That’s because sanitizing and other precautions necessary even with a negative test result add time to each procedure.

“The last thing we want is to get shut down again because we were cavalier or rushing,” he said. “Everything is going to take longer to do than it did pre-COVID. We’re not going zero to 60 right away.”

The Alaska Heart and Vascular Institute has more than 150 backlogged cases, Dr. Steve Compton said. Most of the procedures performed there require intubation. He’s planning to start doing atrial fibrillation procedures on Monday.

“We’re trying to get right up to speed,” Compton said. “We’ve got a lot of COVID testing to do.”

The practice is relying on the state public health lab to do testing. There’s some concern about the risk of having to cancel procedures if testing isn’t done in time, particularly for patients from out of town who are already coming in a few days early to get testing done.

“We’ve been unable to get rapid testing, which would be an obvious answer,” he said. “Hospitals have access but surgery centers generally do not. That’s a statewide bottleneck I see happening that we really have not solved.”

The testing requirements are forcing some practices outside Anchorage to improvise.

The only outpatient surgery center on the Kenai Peninsula contracted with a Kenai clinic to do COVID-19 testing, and a courier to drive samples to Anchorage for processing.

“My concern is our first cases, we’ll expect results back on Tuesday. Which means they need to be swabbed on a Sunday,” said Kristin Hernandez, CEO of Surgery Center of Kenai. “Patients that are waiting may be canceled if their results haven’t come back yet. From a patient’s perspective, that would be very frustrating.”

On Friday the Yukon-Kuskokwim Health Corp., which serves 58 communities in Southwest Alaska, had started testing patients scheduled for appointments next week in the organization’s Bethel clinic, Tiffany Zulkosky, vice president of communications, said over email.

YKHC will also be testing dental providers before sending them to village clinics. Patients in villages will be tested before their appointments as well, Zulkosky said. They’re also screening patients during bookings and at the time of appointments.

“If the village-based patient is in a community without access to testing, YKHC providers will only perform oral exams and cleanings that do not generate aerosols,” Zulkosky said.

In addition to dental services, a limited number of elective gynecological appointments are set to begin on Monday, Zulkosky said. YKHC has also resumed some physical therapy and optometry procedures. They’re still delaying some procedures like colonoscopies and mammograms to help maintain capacity in case of a surge in COVID-19 cases, Zulkosky said.

Reduced risk

Bradford Allen, who owns Allen Dental Group in Eagle River, said he’s planning to see patients who are due for dental cleanings, without using tools that produce aerosols so they won’t need a negative COVID-19 test in advance.

Patients must come alone, Allen said, and staff are adding time in between appointments. They’re also asking that everyone wear masks in the office.

As they’ve called people about their appointments, about half said they’re not comfortable coming in at the moment, he said.

Allen said he is doing emergency appointments but won’t be restarting procedures that do need a test beforehand — routine fillings, cavity treatment, tooth extractions, crowns — because of limited testing availability.

The financial implications at the moment are less of a concern for him, Allen said, compared with making sure he’s treating his patients as best he can.

But still, Allen said he saw a 90% drop in revenue overnight after closing his practice in March. He had to lay off eight of his 10 employees, and is bringing two hygienists back on Monday.

Allen said he secured 90 N95 masks from the Municipality of Anchorage, and that as dentists, they’re used to treating people while wearing personal protective gear.

“As dentists, we treat every patient as if they have some sort of communicable disease,” he said.

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