Seta MacCrory describes herself as a "dental cupid."
She matches up hygienists looking for temporary work with dentists in need of staff through her business, Substitoothfairy, which she runs out of her Delaware County, Pa., home.
Before COVID-19, MacCrory facilitated 300 matches each month. Now that number is close to zero.
On May 8, the Pennsylvania Department of Health set new safety guidelines for reopening dental practices. Since then, MacCrory said, she's been flooded with calls from dentists desperate to restart their practices, but struggles to find hygienists willing to risk constant exposure to saliva and respiratory droplets that could be swarming with the coronavirus.
As a licensed hygienist with diabetes, MacCrory, 36, said she understands her peers' concerns. But she sympathizes with dentists who call her, "crying, telling me they have two more months before they completely fold."
"I see all angles," she said. "My head is spinning. I'm in the eye of the storm."
Saliva, tartar buildup, bleeding gums: As businesses lurch toward reopening, there may be no workforce facing as tough a challenge as dentists and hygienists. The very nature of their work can put them at high risk for the coronavirus. Yet most hygienists work for independent dental practices that must reopen if they want to survive.
On top of all that, numerous dentists and hygienists told The Inquirer, the state's vague protocols do little to help -- and potentially much to hurt.
"We will be right on the front line -- in the mouth, working with the bacteria that spread COVID," said Tahita Ross, a hygienist who is licensed to practice in Pennsylvania and Delaware. "I mean, we can't help but work in saliva. And that's how it's transmitted, through droplets. Now that I'm talking about it, it's like making me scared."
During the initial weeks of the pandemic, the state Health Department advised dentists to suspend any procedures that aren't emergencies. That's no longer the case.
And here's where it gets complicated: Revised state guidelines tell dentists they can now perform nonemergency work -- but they can't "generate aerosols." In other words, nothing that might send patients' saliva out of their mouths and into the air.
The exception: " ... as a last resort when clinically necessary," according to Pennsylvania guidelines.
But in dentistry, aerosolization is virtually unavoidable.
"If there's a patient in the chair and you do anything that gags them or they have allergies and they cough in your chair, there can be aerosols that can be produced even if you are not using a drill or an ultrasonic cleaner," said dentist Michael Barnes, who owns a practice in South Philadelphia.
Lisa Maisonet, a hygienist who helps run 22 Philadelphia-area dental practices, put it bluntly: "Everything we do creates aerosols. Everything," she said. "It's like the state said, 'Here's a swimming pool, jump in, but please don't get wet.'"
Adding to the confusion, the Health Department says dentists should "apply their clinical judgment" when deciding what is safe. They should go ahead with treatment if not doing so would cause "irreversible damage to the patient."
Barnes said some of the Health Department guidelines directly contradict other parts. That creates a heavy burden on dentists to determine the right thing to do in uncharted terrain.
For now, he's decided not to perform routine cleanings, deeming them too risky. But he would use a drill, which can create aerosols, for "a few seconds" to smooth "a sharp edge of a broken tooth that is cutting into the patient's tongue or cheek," as long as he's wearing adequate personal protective equipment, he said.
"I do have concerns that some dentists may swing too far in either direction," Barnes said. "Some may try to get back to normal volume too quickly and risk the spread of the virus. Others may be too conservative and risk leaving their patients with difficulty in accessing urgent dental care."
The vast majority of dentists in Pennsylvania and New Jersey work in privately owned solo or group practices. They remain both medical provider and small-business owner -- a dual identity that requires them to consider the health of their employees and patients, as well as the health of their business.
"All of a sudden, they have to shut down, lay off staff. They have loans and business expenses," said Anjana D. Patel, a lawyer with Epstein Becker & Green in Newark, N.J., who advises health-care businesses. "Once they start opening up, they're not going to see patient flow like they used to, especially with all these protective measures they have to implement. It's not going to be the same for a long time, and some of them may not be able to survive that."
Unlike most medical offices, independent dental practices have not had a larger health system or management organization to help cover ongoing business expenses, such as rent and malpractice insurance, during the pandemic.
While emergency dental work was allowed to continue in most states, including Pennsylvania, emergencies account for just 10% of revenue for dental practices, on average. During the pandemic, general practice dentistry revenue plummeted 95% and oral surgery revenue fell 70% nationally, according to the Levin Group, a dental management consulting firm in Baltimore.
"Physicians who work within a health-care system are more likely to see more emergencies," said Roger Levin, a dentist and the CEO of Levin Group. "The independent practice is going to get hit harder because there are no guidelines, no resources, no administrator getting the PPE together."
Barnes and many other dentists are following the recommended safety protocols: They screen patients for virus symptoms before a visit; take their temperature upon arrival; require patients to wear masks and wait outside until it's time for their appointment; and permit only one adult to accompany a pediatric patient.
The state's order authorizing dental practices to resume nonemergency services said they "should" follow these infection-control guidelines but did not outline specific penalties for not complying. However, the State Board of Dentistry, which licenses dentists and hygienists, can discipline or issue violations to providers who flout infection-control protocols.
"It's very confusing because even in the dental world, none of us knows what's allowed," hygienist Tahita Ross said. "Nothing is mandated for us not to do. It's all recommended."
One hygienist who returned to work May 18 for the first time since mid-March said her dental practice forced her out two days later after she complained that the office wasn't following safety guidelines, including taking patients' temperature and limiting the number of people allowed in the office at one time.
The 36-year-old hygienist from Delaware County asked The Inquirer not to publish her name because she's looking for a new job. She shared text messages that, she said, were between her and one of the dentists.
"Honestly, I am shocked we aren't taking everyone's temperatures!" the hygienist texted on May 19.
The dentist responded that taking temperatures could create a false sense of security and wouldn't prevent asymptomatic spread, the hygienist said and text messages show.
The hygienist also complained about having to fudge chart notes stating a routine cleaning was necessary to "prevent irreversible damage," in order to meet state Health Department recommendations.
"I took a stand and said, 'I'm not willing to risk my license or my family's safety,' " said the hygienist, who has a 6-year-old with a kidney condition and a 4-year-old with asthma. "And they basically said, 'So is this your resignation?' And I had to say, 'yes.' "
Since the Board of Dentistry can penalize practices for not following safety protocols, hygienists are in a difficult spot: Stay quiet to keep their jobs or report their boss to regulators, said hygienist Lisa Maisonet.
"Some dentists are twisting the guidelines so they can make the decision to see anybody they want right now," including doing procedures with instruments that create visible aerosols, by deeming it as "clinically necessary," Maisonet said. "(Hygienists) are being put into a tough situation. Their licenses are really being compromised and it's like -- they have to feed their families."
Ross, the 39-year-old hygienist who was raised in West Philadelphia and now lives in Newark, Del., said her employer plans to reopen for emergency cases only in early June. She said she has reservations about returning to work but sees little option, although right now, she doesn't know who is going to watch her children, ages 10 and 6.
"If schools and camps were to reopen, I would have to go back because I wouldn't have an excuse not to. It would be like a fear of losing my job," Ross said. "I do want to go back to work. I love my job. I will go back as soon as I can."
MacCrory, who runs the dental staffing service, said if dentists can't guarantee hygienists a 40-hour workweek because they don't have enough patient volume, there's little incentive to put their health at risk and return to work. That's because some hygienists are earning more money not working, between collecting unemployment pay and an additional $600 a week from the federal government in pandemic relief. But that won't last forever.
Andrea Pelonero, a 50-year-old hygienist from North Jersey, one of the nation's hardest-hit regions for the coronavirus, said she doesn't understand why hygienists are worried, given that they've always had to take precautions against infectious disease, such as HIV.
"I assume everybody is a bag full of infection at every visit, so what exactly do I need to do differently now?" Pelonero said. "It's like being a nurse -- you knew this when you signed up for it, so I don't understand, like people don't want to do it anymore because now they're scared. What? Weren't you afraid of getting AIDS before? Seriously."
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