SPECIAL REPORT: COVID-19 The Way Forward
In this 2nd Ruddle Show Special Report, Dr. Ruddle and Lisette discuss via Zoom how the dental profession will move forward as the economy begins to re-open. We will discuss what infrastructure needs to be in place to mitigate future outbreaks and control the spread of the virus. Further, we will hear Dr. Gordon J. Christensen’s perspective and learn from him how dentistry will need to adapt going forward. Lastly, we will discuss some of the specific issues confronting dentists in the very near future, i.e. PPE, office design that respects social distancing, safety protocols, and how to communicate to your patients. Remember, we are all in this together!
This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
Welcome to the Ruddle Show. I'm Lisette and you can see next to me my dad, Cliff Ruddle. And we're joining you again today by Zoom to give you another Ruddle Show special report. Last time we talked about how the international dental community is handling the COVID-19 pandemic, and today we want to talk about perhaps how we can move forward from here. Because we have been social distancing and because non-essential businesses have been closed, we've done a lot to flatten the curve. So how are you dad?
I'm doing good. Are you doing okay over there?
Well Lisa and I are used to being in a really – I'm very proud of it; it's a very tricked out studio and we used it in our first 10 shows of the season. But now we're at our respective homes and when I go on my morning walk I go by Lisa's house so you can tell she's not too far away because look at my age and you'll know; I can only walk about 10 feet. So she lives close.
Well yes, flattening has been a really nice thing and the whole world is looking at modeling. So we see the curves; the usual ramp, then the parabolic, exponential, logarithmic curve, the plateau and the decline. The problem is some of the countries that were doing so well that we were looking at as a world have had a few flare-ups, a few hot spots. Like Singapore is an example; they have dormitories that hold maybe as many as 200-300,000 foreign workers and they've had a huge outbreak in those camps. We were pretty excited as a global community looking at South Korea; they knocked it down but now they've had some flare-ups.
So everybody's in a little different place. Some people are going through the curve, Russia is starting to go through the big parabolic curve; some are coming out of the curve and then we're seeing some hot spots. So basically how we're going to move forward is we're going to have to have good data. And I want to bring to attention – there's two people you might want to go to YouTube and look at it a little bit more – but Wolfgang Wodarg, he's a German pulmonologist, very, very recognized around the world in epidemiology and pulmonary diseases. And then I'd like you to also make a mental note of John Ioannidis at Stanford; he's an epidemiologist and he's head of public health.
Well those two guys – I was listening to quite a bit of their content and they're talking about really there's a pandemic they say of bad data. And the bad data is why we had models that projected the United States 1.2 or higher million people dying; deaths. Then it was modeled down to about maybe 750,000; then it got down to 100,000 to 250,000; and today Lisa and I are happy to report that they're thinking that the whole thing might be about 60,000.
So our two guys – I want to say his name correctly –Wodarg and Ioannidis – they talk about the numerator and the famous denominator. And in the numerator we have over and underreporting. The numerator is deaths. Well as Lisa and I have been discovering in the last few weeks, it's not unusual for some country to find quite a few bodies that have accumulated tragically in rest homes; those aren't reported. That's an example of underreporting. Over reporting; it's pretty well known. You talk to a lot of physicians and watch their interviews and if you're in a hospital and you sneezed, you coughed, you had a temperature, maybe you couldn't smell so well; even if you died of a heart attack it was chalked up as COVID-19. That's over reporting.
So deaths though probably are the most reliable thing, even with the recognized error factor; but it's really the denominator that's startling. Lisa had mentioned several times that there's been some studies in Los Angeles. We have a Santa Clara study, we have the Stanford Study; and what they're doing is they're going back and looking over 10-year normal flu season deaths. And what they're finding out is that we have about a tenth of a percent of deaths, or about anywhere from 20-60,000 deaths a year in the US from flu alone.
So what they're saying basically is we're not counting the people that are asymptomatic because they're not even reporting anything. We're not counting the people that are asymptomatic and had a sniffle and told their wife, gee I hope I don't have anything other than just a little flu. They're talking about people that actually get hospitalized. So if you look at the massive amount of people in society that probably either have had it and they're silent carriers or now they're well, or maybe they have some antibodies. The problem is we don’t know the denominator, and if the denominator grows obviously that's favorable because the death rates really plummet.
So the bottom line is we need to have what? We need to have better data; we need to have better modeling, which will come from better data; and we need transparency.
Yeah, I think that it is definitely a problem that we do not even know the extent of the infection. Because we're really just – because of our testing shortage we're really only testing people that seem to be in dire need and fit a certain criteria. So to get back to normal I think that we need to know really the extent of the infection in the first place, and how many – yeah, there's just a lot of stuff we don't know.
So to get back to normal we want to start opening things gradually. Of course for every State in the United States that's going to be different because we're seeing different levels of outbreaks in various States. And even within States in the large urban areas they're definitely being harder hit than the more suburban areas.
So I think that we need to start being – we need to be responsible and gradual with our opening up and get better data. Because we don't want to just throw away all restrictions and then all of a sudden there's major spikes that are turning up and then they're harder to control.
So what, Dad, do you think would be the main things that we need to have in place to start a gradual opening of the economy?
Well we talked in our last show about testing, and you had quite a bit to say about it. And what we both concluded was we really don't have very good testing protocols or availability. Now the gap is closing and we're a lot more seeing more rapid responses to this. But basically initially we had testing that might take anywhere from 24-48 hours; that would have been ideal. But sometimes it was days, and in a few cases it was weeks. Because in supply chain lines you can imagine as we started emphasizing more testing we overwhelmed the labs. And then sometimes the test that was being done the lab didn't have the compatible equipment to actually do the test and it had to sit there for some days before they sent it on to another hospital or even an emergency setting where it could be tested. So that was kind of how it was two or three weeks ago.
But now we have a little bit better reaction with Abbott's promise, and Abbott is now going to – they have this new mobile platform; it's a little device that can go in an office; it's very mobile, portable. And it can test very, very rapidly between five and fifteen minutes. I saw it on television about a week ago and it was tested on a physician who said he was really tired. And they said right on the show we're going to test him, so they did a little swab and what you noticed was they didn't have to go clear up so high towards the nasal pharynx. They were much more shallow in the nose; they put it in with two drops in a machine. And while we were sitting there talking, or while he was talking, seven minutes later he was negative and he said I feel a lot better. He said he noticed he felt better.
So anyway Lisa, we need better testing. Now the question is 50,000 tests a day by Abbott aren't going to close the gap. So obviously these are going to be testing probably in acute areas like hospitals, clinics, when people report illness. But what I think you're alluding to is how do we get back to work. Well how we get back to work is if we could have widespread testing. And I don't know if that's going to happen very quick, but what we might be able to do is what's been done for decades is set up scientific models in various communities – this has to be university control, hospital control – and then test in a random way that population. Then you can get that data and extrapolate it maybe to the whole population in that region. And as we start to know who is clean or negative – maybe they had it and they're negative – we'll be able to send people back to work and it won't be so fearful; it'll be more out of confidence. That's what's going to open up restaurants, ball parks. But that's going to be further down the line. We've first got to talk about little groups coming together to start business.
I think one of the big problems with the testing right now is because we are only testing people who we suspect have it and have it severely, that we're getting basically a positive test for every five people we test. And so that's a pretty high positivity rate and we want to get that down. But it makes you wonder; like are we really flattening the curve or just have we plateaued on the testing? So I think that as tests become more available then we might initially actually see a larger infection because we'll be testing more people. But the hope is that over the long run that we'll start to see a much lower positivity ratio and just hopefully we'll find that the infection isn't as prevalent as it might be if it's one in five for example.
Well yeah, just to play off of you. There was that Santa Clara study, and I know there's been three others but I won't try to remember exactly but they were on this vein. So they're small communities but it was where they had severe outbreaks. And they did random testing and the prognosticated anywhere from 50 to almost 100 times what we know were infected patients; people running around totally asymptomatic with antibodies that they found through serology testing that they already had had it. So maybe we have a lot more infections, asymptomatic infections than we probably think, and that means that drives that denominator way up which lowers the death ratio.
And that of course brings up the importance of antibody tests. But even that is – right now I think there's like 90 companies making antibody tests and they're not getting the FDA approval because the FDA is busy. Basically they said to all the companies, you do your own review of your product and make sure it's working well. Well there's some that are out there that are only like 20% accurate. They say they're like 80-90%, but they're actually only 20% accurate. And there's also issues that they have to specifically be testing for the novel Coronavirus, not just other Coronaviruses that are in circulation also like other colds and stuff. So I think with the antibody tests they've done so far, and of course the results are coming slow because the labs are busy testing for COVID – doing the COVID-19 test. So as the results come in I think they're only finding that a very, very small percentage of the population has antibodies – maybe 1-5% in some areas and 5 would be like the higher end in like more urban areas. Like LA I think they are finding around 5% infection. In New York it might be they say 10%. But still that's a lot of people that haven't been exposed to it.
Or you mean exposed but they're quiet – they're over it – it's passed them?
Or no. If they don't even have antibodies; there's like say 90-95% of the population does not even have antibodies.
I hope that's correct, okay.
And then there's also the contact tracing. That could help once we have the two testing – the antibody test and the COVID-19 test going smoothly and that there's an ample supply then we have the contact tracing. And what do you know about that?
Well we can know from just looking around the world. It's been widely used in China; South Korea comes to mind. And of course who were the two platforms; was it Google and Facebook? But anyway they've already worked it out from a technological standpoint.
Google and Apple maybe? I think it might be Google and Apple, and I think Facebook is doing something else to help.
Okay. So Google and Apple did already collaborate in those countries. And so yeah, there's a lot of talk about it here. And of course in the most pure medical sense it's very important that – you could have an app on a phone, it could be installed. And once you have this app and it's on then basically if you are at the store shopping and you're in a queue and somebody around you has it, they're COVID-19 positive, they could be asymptomatic but it could begin to alert everybody in cellphone proximity to the carrier that they were exposed to somebody that they may or may not even know. So that's kind of encouraging because as you can hustle people off main stage that are carriers and sick, you can begin to define the well people from the sick people and that also can help us get back to work.
Yes. I think is how that contact tracing works is that if you test positive then they can check on your phone and they can see every place you have come in contact with maybe other cell phones I'm thinking. That's how it maybe works and then they can notify.
It's other cell phones. Electronically cell phones are talking to each other.
Okay. And then they can tell those people that you've been exposed to someone who tested positive and then you need to go in quarantine to protect yourself, depending on I guess the extent of the exposure.
And of course there's some hope that we could take blood from previously sick people who have recovered. We could take their blood, centrifuge it, pull off the plasma, get the antibodies, infuse them into another patient that might either be well but wants immunity. Or they might be a little sick and maybe you can shorten and decrease the peak of their symptoms; or maybe give them immunity. But again we don't know, again because we don't know if these antibodies last days, weeks, months or years. We don't know how viable they are. All these are in play though.
I guess it would be nice to know if you were going back to work and to some extent putting yourself at risk in the community depending on your profession. Like if you're a dentist or an endodontist you're going to be actually very in close proximity to people who could possibly be infected. And it would be nice to know that if you did get it that there's treatment available and you have nothing to worry about; you're going to be fine. So what treatments do we have right now that seem to be giving some good results, or are there any?
Well yeah. We – there are some things that are what are called off label. In other words if the FDA or whoever the government agency is for your country, if they approve a certain medicament or a reagent for a specific thing; like if we're talking about hydroxychloroquine for malaria. So that was approved for that application in the '50s and millions of people literally around the world have used it. I have been given it to go on lecture tours in South America as an example. So that is for malaria. Later I think you mentioned yesterday lupus, and then we know some arthritic conditions so it's approved for those. It's considered off label for COVID-19. So what that really means is, serendipity or good things happen by accident, but through serendipity there have been a few anecdotal studies, by important people but just small studies, small ń, not a big population, and they've shown that hydroxychloroquine can actually shorten the duration of the disease and the magnitude. And every now and then you hear but it didn't really help me, and then of course there are some side effects. So that's out there. Every physician is now pretty much able in the US. It's a decision; the FDA allows off label drugs in a compassionate use method, so it's a decision between the patient and the doctor. It's not what you heard on the media or people lashing out at physicians for how dare they use this. It's a physician's decision with their patient if they get it.
Another one that's probably even more promising is remdesivir. Remdesivir is really a non-approved medicine. The company is Gilead and the FDA has now released it for again compassionate use. So again between the patient and doctor; that shows big promise. What remdesivir does is it prevents – it's an anti-viral and it blocks the virus from reproducing itself, replicating its genome. So that's how that works.
Do either of those things, the hydroxychloroquine and the remdesivir; has there been – do you personally know if there's been any studies to show that if those were given at the earlier onset of symptoms that it might be more effective versus later when you're in more danger? Because it seems to me that a lot of people are going to the hospital and finding out they have it when they're already pretty sick. Because of the whole testing shortage you have to be pretty sick to get a test, so it seems like maybe an anti-viral would be better at the beginning of getting sick.
Great point Lisette. Well that's part of the controversy and the unknown, but what you're saying is what more and more physicians are coming forward. Like I heard a guy that runs a big – they're doing a big program now in New York City. He's at I think NYU; yeah, NYU. And what he wants to know if maybe if you gave these a little earlier you can knock down the severity and shorten the duration. So his point was by the time we're getting ready to put you on a ventilator, he said in their studies 80% of the people who go on ventilators never get off the ventilator again In other words it's a death sentence. So there is a lot of interest to maybe move these potentials – I didn't mention Z-Pak but with the hydroxychloroquine often times they'll give azithromycin as a combo drug. And then we mentioned remdesivir. I don't know. Of course we're all shooting for the vaccine, right?
But that's probably still a year to 18 months out I guess.
It's a year out. Now there is tremendous how because of SARS, MERS and all these other things that we've had to deal with that the community can come together – meaning internationally – much quicker. We have way more knowledge; we've genomed and mapped these things. Even COVID-19 was mapped in December. The scientists in the labs in China already had dispensed to the world its genome so that was fabulous transparency by the doctors and scientists themselves.
Okay, so I guess we're working on some treatments and working on the vaccine. So say that your government that's in your area is wanting to relax restrictions, and dentists and endodontists are going back to work. Obviously things are going to have to change a little bit in your office. What about supplies? Are they suddenly going to be available again? You're going to need obviously full PPE, right?
You know you brought up something, and you know your Pop. I'm one to like – there's got to be a balance between lives and livelihood. But as we start to look to starting all over again and getting geared up, your question about the availability of PPE is not a slam-dunk. Because what I've learned is most of our resources for PPE in the US are about 70% from China. And in fact when China started initially having their outbreak, we even sent PPE stuff to help them. Well now we pretty much have a big block in exportations or importations of PPE stuff into our country. So there's shortages all over the world; everybody's competing for masks, gloves, goggles; and that's going to have to be met. We're going to have to gear up.
Now fortunately America is known as a nation of ingenuity and we already are converting car companies that manufacture engines to make respirators, and we are all in on PPE. And I have been hearing recently we will be exporting PPE stuff in two months. We will be sending it to Russia; we will be sending it all over the world where they're still having their curves and their outbreaks.
But to your point, it's nice to say come back but are you going to have to wear a shower cap from your mom's bathroom? Are you going to have to wear some garden gloves? I mean what are you going to be wearing?
Right. And I've also heard you talk about the importance of the booties too.
Oh, that's a song: Shake Your Bootie. Yeah, you've got to wear your booties because you bend over to take your shoes off after the OR, and of course all that stuff in the air settles down by gravity and we all know your shoes are taking a major viral beating. So be sure you keep your gloves on as you take your booties and your shoes off.
Okay, well I think that we have a little video from a friend of yours, Dr. Gordon Christensen. Do you want to introduce that?
It's a great honor and pleasure for me to introduce my friend, Gordon Christensen. You know when we're talking about getting back to work, I can't think of a better person to tell us how we might do that, because Gordon is one of the most respected people in all of dentistry, if not the most introspected. He has done an enormous amount of articles and publications and educational materials, so he's a consummate educator. And I would like you to hear what Gordon has to say going forward. So listen to a master clinician with decades of experience and somebody that we all trust.
Oh, I'll bet your sitting in your bedroom or somewhere in this miserable virus problem. I'm as upset as you are. We stopped seeing patients quite a while ago, and one of the things Cliff asked me to talk about is how many dentists are still doing dentistry? I hope none; because the virus is spreading way too fast. In fact I just saw on the Internet minutes ago that New York, New Jersey, Connecticut and I can't remember how many others, Trump is closing off. And you've seen it close off in many other places. I'm wondering, what are the virologists doing? Where have they been? Why haven't we had preventive orientation in this particular situation? Where are we going?
We'll get over it. I'll say that right now and I'll say it in two minutes when I quit this little dissertation with you. I've been through the Second World War as a kid. I've been through the Korean War as a teenager. I was in the Army at the Viet Nam War as a dentist. We've had SARS, we've had Ebola, we've had polio. As a young kid I went through – I didn't have polio but my mother was so protective we couldn't even go in a store. All of those things have come and they've gone. That's going to happen to this. But many prognosticators say that this will stay with us for years to come. The flu virus that you have been vaccinated for this year; that was years ago and it's still here. So just get ready for it. We should have been doing these preventive things long ago.
Furthermore, what do you do to console our patients? Because when they come back to your practice they're going to say ohhhh, I'm going to get the virus! And you're going to have to say "no you're not". We're preventing in every way. Console them, calm them, tell them about all the things you've done. And by the way, if you want to go under CliniciansReport.org (one long word), CliniciansReport.org, you will see our interpretation of what to do; and it varies quite considerably with CDC and FDA and other organizations, because we have actually done research on these things for 40 years. The things that my wife, Dr. Rella Christensen, indicated – now she's a Ph.D. microbiologist and heavily involved with viruses – none of these groups are doing anything on viruses. Cliniciansreport.org, see what we're suggesting; and it will vary somewhat from what you're hearing from others.
You know, Cliff Ruddle is the god of endo. We have him teach right in our courses here in Utah. I respect him unbelievably. If I had an endo tooth to do right now I'd get on an airplane as soon as they can fly again and I'd get to California. Cliff, we love you. Keep up the good work and make sure Phyllis tells you what to do, will you? We know how those two go together. It isn't just one person.
Dentistry will recover, I guarantee you, as all those other things I mentioned did. And we're going to go back to relative normal. But – I hope the government gets their case together and starts getting more preventive things out there. I hope you or I will change anything in our own offices that don't meet those standards that you'll read in CliniciansReport.org.
Thanks for the opportunity to talk to you for a minute.
Thank you Gordon. And incidentally, I want to thank Rella too. I mean to know Gordon is to know Rella, and if you know Rella you know Gordon. But Rella in her own way for decades has been quite a scientist, and she is heavily behind something that Lisette's going to talk about in just a moment. But the two of them together are synergistic and I think it's 1+1=5. They are their best version.
So Gordon, thanks so much. And thanks for being an inspiration to us and showing us what might look like over that pandemic plateau and how we might get going again.
Yeah, I actually went to Gordon Christensen's website and downloaded his May issue of the Clinician's Report; it looks like this. And it has a lot of really great information in it about getting back to work and things you can do in your office to make your patients feel comfortable. Because they're going to be scared when they come back, and I think Gordon Christensen said that.
And you know he talks about maybe going down to the parking lot and taking their temperature right away with a no-contact thermometer; asking a list of questions that might give you an idea if they've recently been exposed to the virus or have been in a high risk situation. He talks about having the waiting room chairs 6 feet apart. Get rid of the magazines and the newspapers because we don't want people handling those. Put hand sanitizer around your office. Have vacuum ventilation in your operatory so the air can be sucked out. Just a lot of things. And then a lot of information about disinfectants and PPE, and the right kinds of masks.
So I definitely would recommend, and I'm sure my dad would too, that you go there and take a look at this, because it's basically a whole guide that's laid out for you of how to get back to work.
Well Lisa, we haven't talked about this but I guess I should tell the audience just another little story about Rella and Gordon. But Phyllis and I go to Provo annually to help with the workshop course there, and of course many years ago having not been there we got to have a tour by Rella. And Rella took us through a tower with multiple floors of all the research labs that people are working on projects and pending publications. So between Gordon and Rella they've been a bright light to illuminate dentistry for a long time, and there's no difference on this occasion. We can look to them again as a beacon of light.
Yes. And there's one other thing I wanted to mention; that at the end of the Clinician's Report are some CE questions that you can fill out and send in. So you can actually get CE I think from reviewing this Clinician's Report as well.
And he also talks about online CE in this too, and how you can use teleconferencing or teledentistry going forward. Just using the Internet more, incorporating it into your practice; maybe consultations could be by teleconferencing; stuff like that. I think that the way forward is going to change. I think we're going to probably be incorporating teledentistry more into your practices, don't you think?
Oh absolutely. You know already, as you know from us working together as a team for, I don't know, close to 20 years now just in your case. But look at how it was 20 years ago in terms of we wouldn't be doing what we're doing today. And think of 10 years ago; wouldn't have been doing what we're doing exactly this morning. And I wanted to say also about Gordon; in context for his little segment. He did that about three weeks ago when we were probably at the very height of the COVID-19 in New York City.
So everything has context, and I say that because sometimes when we're getting these clips from around the world, like from Fabio Gorni or Patrick Tseng, whoever they were. We had to get those two or three weeks in front of when we actually went live. So you can see this is a moving target and what we would report tomorrow would not even be necessarily what we report today.
I know. Things are changing really fast. I think we've talked a lot about how dentists, what they can do to protect themselves. But I think we also need to be aware that maybe we should ask the patients; what questions do you have for us? So that you feel safe too, because they're going to be concerned and they might have a lot of questions for you. They might be concerned about is everyone in your office going to be wearing masks, or they just might have a lot of questions too.
So I'm going to follow up with that, because yesterday when we were practicing for another skit that you'll be blessed to see soon, we were talking about what's missing. And most things in life what's missing is communication. And what's not said is usually the problem. So when your patients come in, Lisette just said they're terrified; but they're not telling you they're terrified so why don't you speak to what is obvious? And what is obvious is talk to them; find out what they're worried about; bring it out in the open; brag about your systems and structures; hold up your CRA, Clinician's Report; show them you're following the guidelines. Be proud of what you're doing, and that will build confidence and you'll get people to slowly start coming back into the office. Okay?
So for me the start and my close for today isn't going to be like flipping the proverbial switch. It's going to be more like a sunrise. It's going to be like the dawn of a new day; a new beginning; and the promise that we're going to be able to see our patients and make sick people well again. So until then, dream big and best wishes to you in all you do or dream you can.
Yes, and I also want to let everyone know that we already have started filming out second season. We've filmed four shows so far and we're still working on that. I don't know exactly when we're going to get back to that, but in the meantime you can go to our Website and watch the first season; there's 10 shows there. And you can see our two special reports on the COVID-19 pandemic as well.
So I think we're not going to go back to our day, back to our social distancing. What are you going to do Dad?
Well you know me; I'm always working on what's next. So to me I feel alive when I'm working. So to me it's a big pleasure in some respects; it's humbling to have this down time and look at all the livelihoods and lives that have been crushed. But you and I have eternal hope about tomorrow. So we're going to go back to work and we'll have to keep Zooming it and practicing our seasons, but I hope we can be back in our studio to do the next show.
And if not we're going to be creative and do something else. Because I think that we're all learning how to be creative at home now with what we have here. And I know I've been doing a lot of cleaning myself and rearranging stuff. And I know my daughter has been painting; I think we're all finding our creative spirits here.
I'll tell one on you. Sometimes we talk about everything else around us, but there are flies here on the show. But Lisa has a little sunroom, and if you notice the first COVID shoot she was in another environment; maybe a kitchen or something. It was fine. But she got here sunroom; she got that energy – you know that blast of covert energy you always get when you're looking for tomorrow, the dawn of a new day. She was looking at the dawn of the second shoot and so look where she is. Does she not look fabulous?
Well thanks Dad. You look great too.
Okay, well thanks everyone. Thanks for watching. We'll see you next time on the Ruddle Show.
Thanks Isaac, thanks Lori, thanks Phyllis. See you guys. Love ya.
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