A New Normal at One Kneeland

Like the rest of academia, the Tufts University School of Dental Medicine (TUSDM) has faced the challenge of continuing to teach its students as the COVID-19 pandemic has unfolded. But the building at One Kneeland Street in Boston is also the dental home to thousands of patients, and the place where hundreds of future dentists gain the hands-on training necessary to join the profession.

“A dental school is really, in fact, a school and a hospital,” said Professor Emeritus Morton Rosenberg, D74.

The pandemic brought the TUSDM clinic operations—with the notable exception of the emergency service—to an abrupt halt on March 15. When the government allowed Tufts to begin providing care once again in June, it was a different world, and dentistry could not be practiced the way it had been just three months before. Restarting the country’s second-largest dental school, in its compact, 15-story urban tower, became a jumbo task in more ways than one.

“Who would have thought that shutting down would be easier than having to resume?” asked Dean Nadeem Karimbux. “Shutting down was so abrupt. The resumption is much more complex, with so many external and internal factors that are really out of our control.”

Right now, the clinics are slowly returning to about half their previous capacity. First- and second-year students will be attending their classes remotely until January. Hands-on preclinical classes will be divided into small groups, and more use will be made of the Simulation Clinic, where students practice on manikins. Cutbacks in clinical operations and the financial burden of providing a COVID-safe environment have led to employee layoffs and furloughs. For the foreseeable future, Tufts dental will not be the same as it was.

Fewer Patients

As TUSDM entered 2020, its clinics were serving about 625 patients a day. Those patients are treated by predoctoral students and postgraduate residents in specialty programs, under faculty supervision. DMD students need this experience because they will become practicing dentists the day they graduate. The clinics allow students to get their training while providing affordable care for the community.

When the pandemic hit Massachusetts, dental practices and clinics throughout the state had to cease non-emergency procedures. At TUSDM, an emergency clinic remained open, helping relieve the strain on its neighbor, Tufts Medical Center. “We never completely closed,” said Rosenberg. “We treated nearly 1,000 patients during those first three months with a dedicated cohort of staff, faculty, residents, and students.”

To increase safety, the school installed plexiglass barriers around individual operatories. But the largest task was upgrading the air-handling system, which now filters and cleans a complete change of air every 10 minutes. Photo: Courtesy of TUSDM

Oral-health facilities have to take special precautions because many dental procedures produce aerosols—fine particles or liquid droplets suspended in the air—that are an ideal medium for transmitting the virus. That can jeopardize patients, providers, and everyone else in the dental setting; dentists, hygienists, and other dental team members lead the list of non-hospital health professionals most at risk for exposure to COVID-19, said Mark Gonthier, executive associate dean at TUSDM.

When TUSDM was able to start seeing patients for non-emergency care once again, it abided by regulations from the Centers for Disease Control and Prevention and the Massachusetts Department of Public Health. With the new realities of increased infection control and mandatory distancing, treating the same number of patients was out of the question, as much as the school might want to.

“These restrictions were placed upon us, and they place constraints on how much we can do,” said Marc Lemchen, D70, chair of the dental school’s Board of Advisors. But the bottom line, he said, is that the limitations are necessary. “We agree with the importance of the requirements and have followed them to the nth degree.”

Dean Karimbux introduced a four-phase plan, which met university and state guidelines, for moving through the pandemic. By the beginning of September, the school was in Phase 2, with the clinics slowly taking on additional capacity. The third-year students return to the building on September 8, joining the fourth-year students who were present during the summer.

“This has all taken a tremendous amount of work, and if you’re not in the building every day and see it only sporadically, there might be frustration to get it going quicker,” Karimbux said. “Everything that has been done to date has been done in a very prescriptive way, to bring back as safe an environment as we can, for our students and residents, our staff, our faculty, our patients.

“Anything we do has to be built on the fact that this pandemic is unprecedented, and at any stage, we may have to pull back slightly,” Karimbux said.

Changes to One Kneeland

It was far more than a matter of seeing fewer patients and making sure everyone kept their social distance. The school had to secure new personal protective equipment (PPE) for thousands of anticipated patient visits when the clinical ramp-up started, at a time when there were daily stories of national shortages. The building itself needed considerable renovations to become safer—and they had to be done quickly, at an eventual cost of $5 million, which affected the school’s budgeted reserves and the speed at which the school could accommodate more people.

Ronald Davitt, assistant professor, in the PPE that all faculty, students, and residents must wear in the clinics. Photo: Susan Peecher

The dental tower consists of two sections: the original eight floors, built some 50 years ago, and the seven-story “vertical expansion” completed in 2009. Some of the HVAC infrastructure on the lower floors was installed so long ago that computer programmers had to be pulled out of retirement to update the software, Gonthier said. Working within the dense configuration of wires, pipes, and other equipment that lurked above the ceiling tiles—“it was like opening the Central Artery” during Boston’s Big Dig highway project, Gonthier said—presented its own challenges.

The largest task was upgrading the air-handling system, which cycles air throughout the building. The enhanced system now filters and cleans a complete change of air every 10 minutes, and every five minutes in the sugery suites in the oral surgery clinic. The school installed plexiglass barriers around individual operatories and established an enhanced cleaning protocol that includes the use of electrostatic sprayers to reduce any lingering respiratory droplets on surfaces.

Before COVID-19, it cost about $1 per patient to provide PPE for dental team members, Gonthier said. Now it’s $10. Faculty and students treating patients go to a “donning and doffing area” where they suit up from head to toe—bouffant cap, protective eyewear, N95 respirator (individually fitted for each person), face shield, gloves, gown, and booties.

Challenges on a Larger Scale

Clinic revenue typically provides about 32 percent of the dental school’s overall budget, Gonthier said. For the fiscal year ending June 30, 2020, the school anticipated $39 million in revenue from the clinics, but that was before COVID-19. For the current fiscal year, the school’s most conservative scenario anticipates a $22 million drop.

From March to August, as the vast majority of the clinics were either shuttered or operating at a fraction of their capacity, the school continued to pay its workforce, which in addition to faculty includes hundreds of dental assistants and personnel who staff dispensaries, sterilization units, and front desks.

But with fewer patients to serve, additional expenses, and less revenue, Karimbux announced in late August that the school was reducing its workforce by 195 employees, through a combination of layoffs, furloughs, reduced hours, and retirements. “This was a very difficult path to go through, for we so valued their commitment to the school,” Karimbux said.

Joy Kasparian-Federico, J92, D97, DG01, an orthodontist who is president of the Tufts University Dental Alumni Association, said that the news was very sad, but indicative of what the whole dental profession is going through. “Many of us have had to make similar decisions in regard to our own practices,” she said. “All dentists have been hard-hit by this pandemic and the dental school has had the same challenges on a much larger scale.”

TUSDM leadership hopes the clinics can be operating at 50 percent capacity by the end of 2020, but they’ll likely not be back to full capacity for at least two fiscal years, Gonthier said.

If there were to be a quick, significant development in COVID-19 detection—one that might allow daily diagnostic testing, for example—or a vaccine, TUSDM might be able to accelerate its clinic plans. “But until that happens, we will continue to practice within state and national guidelines,” Karimbux said. “I’m confident that everyone here has done as much as possible in our current clinical setting to provide for the health and safety of all who provide care, and for our patients.”

Helene Ragovin can be reached at helene.ragovin@tufts.edu.