Beyond Oral Comprehension
Liberal interpretation of DOH reopening guidance draws ire of dental support professionals
Have you ever tried to locate the "N95 mask" setting on your microwave oven? How long do the instructions say to leave it in for?
If the idea of reheated personal protective equipment (PPE) leaves a bad taste in your mouth, imagine being the Pennsylvania dental support staff forced to resort to such an extreme measure. That's just one of the horror stories that Lisandra Maisonet, government relations chair and member-at-large for the Pennsylvania Dental Hygienists' Association (PDHA), has heard from an inadequately supplied hygienist or assistant in one week. Beyond the scope of her official titles and duties, Maisonet is a strong personal advocate for these support staff, listening to their needs and concerns and ensuring they are adequately protected.
On Friday, May 8, the Pennsylvania Department of Health (DOH) released revised guidance on COVID-19 operations for dental health personnel, stemming from a statewide executive order Gov. Tom Wolf had signed two days prior. That order affords "health care practitioners protection against liability for good faith actions taken in response to supplement the health care provider workforce during the COVID-19 pandemic."
Pennsylvania Secretary of Health Dr. Rachel Levine cautioned that the guidance was not to be viewed as a permission or blessing to resume routine dentistry (cleanings, etc.), but rather a "step forward to eventually return to the full scope of dental practice." Nonetheless, the prohibition of "non-urgent/non-emergent care" was lifted — leaving it to the discretion of dental providers as to whether they should reopen their offices for non-emergencies, specifically in instances where forgoing treatment would cause patients irreparable harm (i.e, a "good faith action").
Despite Dr. Levine's admonitions, the guidance does leave room for interpretation. No one would argue the importance of oral health to overall health or that skipping out on regular dental checkups and cleanings can cause major problems down the road. Following that logic, there's no question that every single dental practice in the state should resume scheduling a full slate of appointments. There are a couple of caveats, however — the availability of PPE (googles, shields, masks, gloves, gowns, etc.) and the limitation on procedures that create an aerosol (spray or particulates that could be interspersed with infectious droplets).
It's because the bulk of PPE is being routed to hospitals and frontline emergency workers (as it should be) that dental staff are being forced to either wear the same mask all day or even all week (or one that doesn't fit). While many dentists have chosen to remain closed for this reason, others have told the state that they have "everything they need" — putting their staff in a precarious position. "Hygienists want to go back to work," stressed Maisonet, herself a registered dental hygienist representing hard-hit Bucks, Montgomery, Philadelphia counties. "But they want that personal protective equipment."
A worn or ill-fitting mask does virtually nothing to prevent transmission of COVID-19 or other respiratory illnesses. Nonetheless, some dental offices in deeply Red Phase counties have proceeded to ramp up operations. Even those in Yellow Phase Erie County have not been totally exempt from shortages of PPE. Maisonet joins many of her peers in the belief that practices should accommodate emergency appointments only until adequate PPE is available. "What we do is important, but we need to do it safely and smartly."
Not to mention correctly — which is difficult without the usual full complement of equipment at a dental hygienist or assistant's disposal. Ultrasonic scaling (plaque and tartar removal via high frequency sound wave), suctioning, rinsing, and polishing — the devices that perform these tasks all create an aerosol, yet are crucial for a thorough cleaning. Without that technology, staff are relegated to hand instruments, which can "move plaque, but won't disrupt bacteria," Maisonet explains. Left undisturbed, the layer of bacteria and other microorganisms throughout the mouth known as biofilm can have devastating inflammatory impacts.
There are financial repercussions as well. Take for instance a more extensive procedure like placing a dental implant — a scenario one hygienist conveyed to me personally. When this is done without water (which naturally produces a spray), the bone heats up, encouraging osteonecrosis (bone death) and the probability of a failed procedure — one that usually runs for about $3,000. Hygienists locally and throughout the state have bristled at delivering a lower standard of care at the same cost, and the potential breach of trust that is the bedrock of the patient-provider relationship.
"Why are we open? What are we doing for these people?" the hygienist asks herself. "You're not even getting half of what you're paying for."
If dental health professionals are asking these questions, then you should be too. Throughout the remainder of the pandemic and beyond, do not hesitate to seek dental care if you need it — especially in the emergency event of a chipped or broken tooth, pain, swelling, or infection. But do not hesitate to stand up for your rights as a patient and hold care providers accountable either. Are your best interests being served, or theirs?
If good faith words are met with good faith actions, maybe we can all come out of this smiling.
Matt Swanseger can be reached at firstname.lastname@example.org