The Dental Hygiene Dilemma
To clean or not to clean, that is the question. Yes, OK, that’s an over simplification. After all, dental hygienists do not clean teeth, patients clean their own teeth. We scale teeth to prevent disease, we inject local anesthetic prior to treating periodontal disease with non-surgical periodontal therapy, we educate patients about diseases and the ways they can prevent and treat them, we polish teeth and prostheses (crowns[caps]and bridges) to remove stain and extend the life of said prostheses that can cost tens of thousands of dollars (sometimes over one hundred thousand dollars, yes, you read that right) depending on how many you need, apply preventive sealants and fluoride treatment (yes for children, but also often to protect that investment I just mentioned), expose radiographs, remove sutures, this list goes on for a while, but you get the idea. They’re referred to as the PET services: preventive, educational and therapeutic. Unfortunately, a lot of the public still see the registered dental hygienist as “the cleaning person.”
With many businesses opening back up this week and in the coming weeks, I feel it’s a good time to use the educational part of my PET skills for the benefit of my fellow RDHs and the benefit of anyone else who ends up reading this.
In my 20 plus years as a hygienist I have always gone out of my way to make sure that the patients I treat have a thorough understanding of their treatment options, sometimes to my employers’ dismay. Just because something is “the best” treatment option doesn’t necessarily mean its best for the patient in front of me. I’ve always preferred to educate people about all the options and the benefits and detriments of each so that they may make the decision that is best for them. Shortly (and in some states, presently) people are going to be encouraged to get back to business as usual, and that includes going to the dentist. In my opinion, the ability to make an informed decision as to whether or not one should return a dental office for preventive care is no different. Currently, the CDC has this posted on their website:
“Postpone Elective Procedures, Surgeries, and Non-urgent Dental Visits
Services should be limited to emergency visits only during this period of the pandemic. These actions help staff and patients stay safe, preserve personal protective equipment and patient care supplies, and expand available health system capacity.”
On May 6th, several key figures from the American Dental Association (the ADA) wrote a letter to the CDC saying (among other things), “The latest CDC guidance (as of April 27) is still appropriate for those parts of the country where COVID-19 infection rates are accelerating or peaking…However, the situation is much different in areas where infection rates are now declining — and the risk(s) of acquiring or transmitting COVID-19 are very low. It is critical for dentists to have a new or revised guideline recognizing a risk-based approach.” (I’ll get back to this idea in a bit.)
At the time of this writing (5/9/20) there are massive amounts of Facebook discussions and text threads going around among dental hygienists (with plenty of commentary from dentists) about how they now have schedules full of patients who are set to receive dental prophylaxes (a preventive “cleaning”). Basically, an elective procedure. So my question is, when did it become an emergency to have your teeth cleaned? Now don’t get me wrong, I obviously think prevention is vitally important. I’ve spent nearly half my life educating people on the benefits of preventing disease now in order to try and avoid the need to treat it later. But there’s no way I’d lie down in a healthcare facility in a “hot spot” right now with my mouth open for 30–60 minutes without a really good reason, least of all a dental office. The reason? The air in dental offices is filthy and it always has been, even under the best of circumstances. We often use equipment that produces aerosols and studies have shown that those aerosols can linger in the air anywhere from 25 minutes to 3 hours, depending on who you ask. And in an office with poor air circulation? Some say 17 hours. In spite of those facts I am not a germaphobe, I do not perpetually wear a mask at my office and I am not often ill because the good news is, a lot of the organisms aren’t harmful, and those that are generally aren’t deadly if you’re a healthy person. But that’s obviously not the case right now with the novel coronavirus pandemic underway. So what do we do?
Well the biggest answer seems to be that the hygienists will no longer be able to use some vital pieces of equipment, the ultrasonic scaler and the air polisher (they are two of the top producers of aerosols). We will only be allowed to hand scale and use the slow speed polisher. That’s easy for the dentists to say to us because they aren’t the ones who’s careers are going to be put on hold or end prematurely because of chronic musculoskeletal pain often acquired from constant hand scaling. And many patients prefer the ultrasonic scaler, partly for comfort and partly because we have educated them as to the benefits of the machine. Same goes for the air polisher. The dentists hand pieces (drills) also produce aerosols, and we have yet to be informed as to what degree the dentists intend to keep drilling (although they too have been advised not to perform elective procedures). Its pretty hard to do most dentistry without a hand piece. And neither dentists nor hygienists are supposed to use as air/water syringe to spray away debris, also a big impediment to dentists trying to do doing high quality dental work. And all of this is supposed to be avoided because the personal protective equipment (PPE) needed to use it all safely is in short supply. Which brings us to the next big controversy. The PPE.
The most heated conversations going around on the Facebook group pages revolves around PPE. What are we supposed to wear? Can we even get it? The CDC, OSHA (the occupational safety and health administration), the ADA, and the ADHA (the American Dental Hygienists Association), among others, all have “guidelines” for which PPE is required for which kinds of procedures. Unbeknownst to most people (sadly, even many dental healthcare workers), the ADA is not a regulatory or enforcement agency. Neither is the ADHA. The CDC has some regulatory and enforcement authority obviously, but leaves a lot it up to local officials. OSHA generally doesn’t inspect small work places without a complaint being lodged first. It is up to the individual dental employers to follow the “best practices” to ensure a safe work space. As we have all witnessed the last few months, a lot of the standard rules for PPE and best practices have had to be relaxed because the PPE healthcare workers really need right now isn’t necessarily available. This leaves a whole lot of room for “interpretation” of the guidelines. There are stories of dental healthcare workers being told to wear two “regular” masks and that will be the equivalent of an N95 respirator (not true). Workers are being told that if they don’t like the PPE being provided they can buy their own (the employer is responsible for purchasing PPE). And exactly what is the “best practice” for a healthcare worker who has no choice but to work within 12 to18 inches of a person’s face? The OSHA recommendation for treating a well patient when no aerosol is expected to be produced, is to wear a level three surgical mask (as far as respiratory protection is concerned). But what about the well, asymptomatic carriers? In mid-April there was a news report regarding 397 people at a homeless shelter that were tested for the coronavirus. Of those people, 146 people tested positive, and NOT ONE of the those who tested positive showed any sign of being ill! A level three mask won’t protect you from that. And guess who’s at the most risk from those asymptomatic patients? The patient who comes in right after that. That patient most likely won’t be wearing any kind of a surgical mask or N95 respirator, and for some portion of their time in the office, they won’t be wearing any mask at all. And all that, the risks to staff and patients, is why dental hygienists are concerned about returning to work.
Massachusetts, like a lot of places, is slated to begin reopening on May 18th. And from what I’ve read, the dentists would like to get back to business as usual as soon as possible. I can understand this. I would not want to lose a business I had spent years building; I would not want to be unable to pay back the hundreds of thousands dollars in debt acquired to become a dentist. In areas of the country where the risk of contracting the virus is low, I myself would feel comfortable returning to work. But in the coronavirus hot spots, like Massachusetts, is returning to work a few weeks or months earlier worth risking staff and patients’ lives? And should we really be using up PPE on elective procedures when the need in the hospitals is still so high? In my opinion, it is blatantly unethical for hygienists to be performing elective procedures in areas that still have widespread community spread of the coronavirus. Unfortunately, we have very little say in whether or not we do so. If we don’t, we risk being fired and unlike nurses, dental hygienists do not have unions. We also generally don’t work in settings with long chains of command and human resource departments to whom we can turn when we have concerns. Most states don’t even have a board of registration in dental hygiene that governs us. Most of us answer to the board of registration in dentistry. Dentists control us and we are at their mercy. Now more than ever.
