In the age of COVID-19 there are few routine health care procedures with as much close and extended contact as a dental visit.

Dental offices across Minnesota — shut down in mid-March for all but emergency services because of the state’s stay-at-home orders, were able to start offering broader services again on May 11.

But a lack of personal protective equipment (PPE) remains a major limiting factor preventing dental offices across the state from returning to a full schedule of services — particularly the scarce supply of N95 and other face masks.

Preserving PPE for emergency and urgent care was one of the reasons the state restricted dental services.

Dentists, many of whom are also small-business owners, during the shutdown and since have scrambled to keep abreast of new safe operating procedures being recommended by the Centers for Disease Control and Prevention, the American Dental Association and other regulatory and industry associations.

As they reopen, they are finding they have to compete for PPE supplies not only with their fellow health care providers but a whole host of other industries looking for the same or similar supplies.

Mendota Heights-based Patterson Cos., one of the major suppliers in the dental industry, has had to limit orders for certain protective equipment, including N95 masks, since February.

Patterson’s competitors in the dental-supply market — Henry Schein Inc. based in Melville, N.Y., and Benco Dental in Pittston, Pa. — have also had to limit orders of PPE.

Eric Shirley, president of Patterson Dental, said the company pre-COVID used to sell dozens of N95 masks a month. Now, demand is for hundreds of thousands — even millions — of masks each month from dentists and other industries.

Since February, Patterson’s supply chain teams have been working nonstop to fill the gaps.

“First thing we really had to do was identify some new sources of supply. Once you identify that source you have to do your best to qualify that source according to your own process.” Shirley said.

Patterson still does thorough vetting, he said.

“We still run that process. We don’t cut corners just because we are in a rush to get some new product,” Shirley said.

In the meantime, associations and health experts have been trying to get the latest information to dentists.

“Its been a whirlwind of information and communication over the last month and half for our members, its been trying times no doubt,” said Carmelo Cinqueonce, executive director of the nonprofit Minnesota Dental Association, which represents about 3,000, or 70%, of the dentists in the state.

Dentists and dental practices are no strangers to infectious control procedures.

“They’ve been doing this for quite some time. Clearly, COVID-19 introduces a new virus into the equations with some unique characteristics,” Cinqueonce added.

Patterson also has been doing its part to help keep dentists up to date on best practices and procedures.

Patterson’s dental business represents about 43% of its annual sales of $5.6 billion. The rest comes from the animal health unit.

Patterson developed a resource center on its website for both the dental and animal health sides to help their customers navigate through business closures and reopenings.

“We are providing webinars and other educational resources that help our clinicians and other customers get through the today of it, and how do they come out of it on the other end and quickly regain footing for their business,” said Todd Marshall, Patterson’s chief marketing and digital officer.

Dental offices are complex work environments. They include air, water and gas lines, X-ray machines, computer systems, waste recovery systems and other complicated equipment — some of which are not used to being shut down for long periods of time.

Among the resources that Patterson Dental has been providing customers is a 28-page “Reopen and Restore” manual.

Despite being able to reopen on May 11, many dentistry practices took additional time to make physical changes to offices, create new procedures for handling customers from the time they arrive to the time they depart, adopt new sanitizing procedures and reboot systems that may have been idled.

Jim Nickman’s Metropolitan Pediatric Dental Associates has four offices, eight dentists and about 80 employees.

Nickman, also president-elect of the Minnesota Dental Association, said large suppliers Patterson, Henry Schein, Benco and even 3M have been important resources.

“The people I work with have done an aboveboard job helping practices survive,” Nickman said. “They are doing everything they can to supply us, especially with the abundance of counterfeit and non-legitimate product out there.”

But with the limits on PPE equipment, the practice has been carefully scheduling patients and procedures while keeping on eye on the supplies each visit will require. Employees also must be mindful that some dental procedures and tools produce fine aerosol mists that have the potential to carry viruses.

Waiting for those aerosols to settle or get filtered out also limits the number of procedures that can be done in any one dental chair per day.

Last week Nickman said his office was open but only operating at about 5% to 10% of normal capacity. He is hoping it will be up to 30% of normal business on Monday.

“Hopefully by July or mid-July maybe the new normal for us will be about 70% of what we were doing pre-shutdown,” Nickman said.

Amber Cziok, dentist and owner of Sibley Dental Suite PLLC in Litchfield, said her practice is 75% to 80% back to pre-COVID levels.

But while the two dentists and 12 employees at the office used to routinely work 4½ days a week, the office is now open a full five days. They are sometimes working longer days as well to serve fewer customers while they allow for air to settle in exam rooms between patients and for additional cleaning.

Some practices are tacking on PPE surcharges. Cziok’s hasn’t yet, but she said the added costs are an issue.

“It has quite extensively increased our overhead,” Cziok said. “We have yet to get insurance companies across the board to pay that.”

Shirley believes supplies of the broader categories of PPE equipment like gowns and shields have already improved drastically over the last two to three weeks with the exception of the availability of critical masks.

“I’d expect the masks to get better over the next 30 days,” Shirley said.