As the number of new cases of the novel coronavirus confirmed each week continues to drop and retail stores and restaurants across Nevada gradually reopen their doors, so, too, are dentist’s offices beginning to welcome patients back for some non-emergency procedures.

Unlike other businesses, dentist’s offices weren’t required to entirely shutter during the state’s stay-at-home order in March and April, but they were required to significantly limit the kind of procedures they performed. For instance, if a dentist had put a temporary crown on a patient’s tooth and the crown broke, the dentist could put on a new temporary crown; the dentist couldn’t, however, give the patient a permanent crown.

That has now changed.

Since the beginning of the month, dentists and dental hygienists have been allowed to resume non-elective dental procedures under a memo issued by the state Department of Health and Human Services and adopted by the state Board of Dental Examiners. Elective procedures, such as veneers, teeth bleaching and periodontal plastic surgery, are still a no-go for the time being, but most other procedures are once again allowed.

Nevada is one of at least 25 states that has resumed non-emergency dental procedures, but dental hygienists argue that it’s happening too soon. The Nevada Dental Hygienists' Association, as well as individual hygienists across the state, are raising concerns that they don’t have the appropriate personal protective equipment that they need to keep them safe as they return to work. Some are worried that they might lose their jobs if they refuse to come back and wish they had more concrete guidelines about personal protective equipment to hold their employers to.

“We have received 212 messages from hygienists who have been fired, who have been threatened, who say they have to reuse PPE because the guiding documents we have are vague and they contradict each other,” said Lancette VanGuilder, legislative chair for the Nevada Dental Hygienists' Association. “We want to go back to work. We want to be safe. We’re frustrated that we can’t get more clear guidance and that nobody is addressing the massive shortage of PPE.”

But Dr. Antonina Capurro, the state’s dental health officer, believes the state has given dentist’s offices appropriate guidance about how to safely start resuming some procedures. For instance, the memo notes that dental hygienists are still not allowed to use ultrasonic scaling devices to clean patients’ teeth because of the potential to aerosolize the coronavirus from a patient who is infected but asymptomatic.

“We’re really conservative in this first phrase. There’s no elective procedures, no use of ultrasonic instruments. We’re focused on that public health burden and addressing disease in patients. That’s really what the focus is,” Capurro said. “Where we are in Nevada is really in line with guidelines from the American Dental Association and from the American Dental Hygienists' Association. We’re not as expansive as some other states that have opened everything up.”

However, several hygienists, in interviews with The Nevada Independent, still raised concerns that any procedure they perform under the status quo has the potential to create an aerosol. For instance, they suggested that if a patient coughs during a procedure, that potentially could aerosolize the virus and open up themselves, other staff in the office and other patients to exposure.

“As soon as someone opens their mouth and we put our hands in it, we start aerosolizing whatever is in there,” said one dental hygienist in Northern Nevada, who asked to remain anonymous to speak freely about concerns with returning to work. “That’s always been a risk we’ve taken, but this is much bigger.”

On top of that, VanGuilder noted the kind of work that dental hygienists are allowed to perform right now — hand scaling, or removing plaque manually with a metal scaler — isn’t the current best practice for teeth cleanings, which usually involve use of an ultrasonic scaler. Hygienists also aren’t currently allowed to polish teeth.

“You can probably poke around and charge somebody a hundred bucks and send them on their way,” VanGuilder said. “But that isn’t considered the standard of care.”

Hygienists also worry that while they may not be allowed to use devices that aerosolize the virus right now, dentists are allowed to use their handpieces, which could aerosolize the virus and leave it lingering within their office space for a couple of hours. Unlike hospitals designed to care for infectious patients, dentist offices aren’t equipped with negative pressure rooms that help isolate pathogens; at best, they might be able to use a high volume evacuator or a dental isolation system to minimize the risk.

“As soon as you open a door, even if it is a post-op room, because it’s not a negative pressure room, you’re potentially releasing everything into the hallway,” the dental hygienist said.

Phil Su, general counsel for the dental board, said he understands how that circumstance might pose concerns for hygienists. However, he said it is up to the dentist and the office staff to implement mechanisms to keep all employees and patients safe.

“In those types of situations, it’s really a discussion that has to be involved with all the staff in the office that might be subjected to that particular aerosol,” Su said.

Capurro also noted that dentists have devices they can use to minimize aerosols, including a kind of plastic guard that goes around an individual tooth to isolate it from the rest of the mouth.

In the case of the Northern Nevada hygienist, the employee was able to raise concerns at work about the safety of returning until more personal protective equipment is available and was allowed to continue to stay home for the time being.

“With me, I would like to return to work when there’s no more shortage” of personal protective equipment, the hygienist said. “I don’t want to be that person that takes it away from the COVID clinic that needs it, that’s been wearing the same N95 mask for the last month, sterilizing it for the last month and hoping it’s sterilized.”

However, other hygienists reported not having that kind of open communication with their employers, who are typically dentists themselves. They said they understood the financial pressures their offices are facing to resume non-emergency procedures but still believe the risk is too great.

“I sympathize with the doctors because they’re trying to keep their practices open and I would like to have a job to come back to so I don’t want to jump the gun and say it’s not safe for patients to come in, I just feel like there’s some unknown,” a dental hygienist in Las Vegas, who also asked to remain anonymous, said. “We deserve to be protected just like health care providers. We are health care providers.”

Another hygienist who works in rural Nevada, who also asked to remain anonymous, described returning to work as a waiting game.

“Initially, I was asked to come to work, and I said, ‘Well, do we have X, Y and Z?’ and the answer was no, and I said, ‘Well then I’m not coming until we do,’ and the answer I got was, ‘Well then I can’t guarantee you’ll have a position when you do come back. You may be replaced,’” the hygienist said. “I want to go back to work. I’m just waiting for them to have the proper PPE.”

Capurro said the Nevada Dental Association is in the process of trying to acquire a starter bundle of PPE for each of its members. 

“I think that would alleviate some of the concerns from the hygienists if they knew they had received at least the highest level of PPE available,” Capurro said. “I don’t know if that’s a possibility. There’s a lot of work behind the scenes to see that through.”

Nevada Dental Association Executive Director Robert Talley referred all questions for this article to the association’s president, Mark Funke, and government affairs chairman, David White, neither of whom responded to multiple requests for comment.

Capurro also acknowledged the hygienists' concerns that those who don’t have good relationships with their employers might be in a more difficult position when it comes to talking about workplace safety.

“I feel like they may be nervous to have that conversation with their provider or feel like they had inadequate PPE before and they’re worried about what it’s going to look like now,” Capurro said. “I think the board is there to help if there is an issue. They’re the regulatory body. But who wants to report their boss? That’s a very difficult position.”

It’s also complicated by the fact that the hygienists' association continues to broadly have concerns with the dental board, which saw several members and two top staff members resign after a scathing audit last year. The board again recently lost three members, and both Su and the board’s executive director just started their positions in the last couple of weeks.

Su said he wasn’t sure why the board members resigned but he was optimistic that those positions would soon be filled and the board could meet again. It had to scrap a meeting scheduled for Tuesday because it doesn’t have a quorum to meet.

The hygienists' association has also raised concerns that the dental board voted at its meeting last month to not follow the CDC’s recommendations for dental settings during the pandemic. But Su said that move was more about making it clear that the board would allow certain non-emergency procedures to again resume, since the CDC is still recommending that dental services should be limited to only emergency visits. The federal agency has also noted that dental providers should practice “according to their state dental practice acts or other relevant regulations.”

“[The CDC’s] most recent guidance hasn’t yet reflected rollout of non-emergency procedures, and the board wanted to note that by declining to adopt the CDC guidance,” Su said. “That being said, the guidance that we did adopt definitely doesn’t throw the CDC guidelines out the window. They’re definitely useful as far as all the other safety and workplace precaution language.”

Hygienists have also raised concerns about the fact that the board struck a couple of lines from the Department of Health and Human Services memo when it adopted it, including one that says that “all disposable PPE should be changed or disinfected between patients.” However, Su said that has more to do with the ongoing PPE shortage and whether PPE can be reused, as it is in hospitals treating COVID-19 patients.

“It’s more a matter of whether you have to throw out an N95 mask after each procedure. Because there’s such a shortage, if that mask hasn’t been taken off, for example, maybe you can depart from that kind of guidance that would normally strictly apply,” Su said. “It’s a reflection of the shortage that is ongoing.”

Capurro also noted that health care providers are still required by state regulation to follow infection control and disinfection guidelines from the CDC released in 2003 and 2008, though VanGuilder described those guidelines as from the “olden days” and said they don’t have enough details about how to prevent transmission of aerosols. (Dental professionals are typically most focused on preventing the transmission of bloodborne pathogens.)

As far as what would make them feel safe to return to work, several hygienists said they would like to see more guidance from the Centers for Disease Control and Prevention and from the Occupational Safety and Health Administration. In the meantime, hygienists are hoping to at least receive clearer guidance from the state Department of Health and Human Services and state dental board about the kind of personal protective equipment that offices must have on hand for each type of procedure. They believe that would at least allow them to have a document to hold their workplaces accountable to.

VanGuilder said that one of the hygienists’ concerns is that the current memo is too vague and leaves too much up to the discretion of the dentist.

“We know the loopholes, and we know what words people are going to be picking out of that document,” VanGuilder said. “It’s vague, and it’s unclear.”

Capurro is working with the dental hygienists' association and the dental association to come up with a new set of state guidelines. She is hoping to create a one-page memo that would lay out guidelines for all staff in the dentist’s office, including front office staff, dental assistants, dental hygienists and dentists themselves. 

The hygienists' association, by contrast, would like to see something a little more detailed than that with specific requirements about which types of PPE to use in which situations. The group meets again Monday to discuss the new memo.

Capurro, who is a dentist, noted that part of the problem is rebuilding trust between dentists and dental hygienists, particularly in the wake of a highly controversial bill proposed during the 2019 legislative session to create a new type of dental practitioner, known as dental therapists, in Nevada. The bill, which was supported by dental hygienists and opposed by dentists, passed, but with significant limitations.

“I’m really trying to change that narrative and bring everyone together. It’s a common goal,” Capurro said. “We all want to safely treat our patients.”