Why you can’t get your teeth fixed in CA: Dentist need masks
In mid-March, Gov. Gavin Newsom’s administration appeared to throw a lifeline to thousands of dentists who were terrified they would have to close their offices, leaving cavities unfilled, cleanings unscheduled and dental diseases undetected.
As one of the most dangerous professions for catching airborne infections, the dentists were anxious to build a stockpile of personal protection equipment just like California’s hospitals were doing. State officials promised to deliver masks that would have helped dentists provide at least some level of basic services to patients.
“Per our phone conversation, the dental association will get 1 million N95s,” a California Department of Public Health official, Trang Nguyen, emailed to the California Dental Association, on March 13. “Please give me a confirmation later on your trucking arrangement.”
Richard Stapler, an association vice president, replied that four big rigs would arrive to pick up the masks from the state’s warehouse the following week. Stapler, who lives in Sacramento, made the drive to the Fresno warehouse himself. He watched the pallets of masks get loaded into the 53-foot-long trailers, and hauled away to his association’s distribution facility in Reno.
“The next day, after picking up the masks, we got a request – well, it was more than a request – the state ordered their masks back,” Stapler said.
Last week, the governor said healthcare providers could resume doing routine, non-emergency treatments. But the state’s 36,000 dentists aren’t ready.
The Newsom administration’s last-minute reneging on the mask deal was a crushing blow for California’s dentists. One million masks would have been a good start on a stockpile of protective equipment necessary to avoid airborne particles as they drill and scrape, their faces often inches from a patient’s open mouth.
An April 7 memo from state health officials effectively closed dental practices across the state, except for patient emergencies. That order was recently lifted, with caveats, but dentists say they’re not sure how to proceed and are still scrambling to find enough equipment to re-start their practices.
“We need PPEs, face shields, gowns,” said Dr. Stephanie Sandretti, a Sacramento and Roseville dentist on the California Dental Association’s government affairs council. “That is what we are looking for.”
For their part, dentists are looking for the same urgent attention that has been lavished on other medical professions during the COVID-19 outbreak.
Stapler said dentists feel that they are being overlooked by the state and the federal governments, which have focused on hospital workers and first responders, despite the role dental offices provide in health care. He said many small dentist operations are on the brink of closing because “they can’t get clear guidance” from the state.
“Oral healthcare is healthcare. The mouth is part of the human body,” Stapler said. “You’re cutting out an entire part of the human body of the healthcare system by overlooking dentistry.”
In a response to a list of questions from The Bee, the Department of Public Health replied with a brief unsigned statement that said if dentists have concerns about supplies, they should contact their local public health department or Medical Health Operational Area Coordinator.
The department did not address a question about why officials took the masks back.
Dentists face risks from COVID-19
Dentists across the state began scaling back practices in mid-March as the pandemic threat grew. Then came the April 7 memo from California health officials who told dentists to essentially shut down normal work at their offices, noting the risk from “respiratory droplets produced when an infected person coughs or sneezes.”
The guidelines noted that drills, ultrasonic scalers, air-water syringes (all common dentist tools) also “create a spray that can contain contaminated droplets.”
Dentists were ordered to postpone routine procedures, surgeries, and non-urgent dental visits. Only those procedures that required immediate care such as uncontrolled bleeding and severe pain were allowed.
Since then, dentists are seeing patients on an ad hoc basis, taking care of emergency problems only, and they say they’re refraining as much as possible from using the tools that create a lot of aerosols in the office to minimize the risks.
California Dental Association spokeswoman Alicia Malaby said 97 percent of dentists are completely closed or only seeing dental emergency patients.
“Dentists are not generating revenue, however, many of their expenses like student loans, office leases and equipment payments must still be paid,” she said. “In cases where dentists are trying to keep staff on payroll, the situation is more dire.”
The association estimates that up to one in four dentists might be forced to close their businesses permanently if the COVID-19 crisis keeps them out of work much longer.
Being forced to give back their emergency supply of masks wasn’t the only frustration for dentists. They say they’re also frustrated by a lack of guidelines from state and federal officials that would advise them how to care for patients when they open back up.
Last week, the governor said healthcare providers could resume doing non-emergency treatments. Dentists were originally unsure if they were on the list of providers who could start work, but an April 28 memo from the governor’s office listed them behind doctors as “Essential Critical Infrastructure Workers” in the healthcare sector.
This week, Sacramento County became the first county whose health officer’s coronavirus order – in effect 11:59 p.m. Friday and lasting until May 22 – explicitly expands dental activities to “prevention” work.
Dr. Peter Beilenson, Sacramento County’s health services director, said last week the revised order allows dentists to do basic procedures including teeth cleaning. The county later clarified that because the U.S. Centers for Disease Control and Prevention still recommends only emergency care, the dentists should hold off until the state issued its guidance.
“We’re eagerly awaiting state guidelines,” said Sandretti, the Sacramento dentist. “Oral health is huge. We are excited to get back in there. We just want to be safe. We want the guidance to make sure we are doing everything we can to be safe.”
The dentists hope the California Department of Public Health will issue a new set of guidelines for dentists to begin expanding their services, possibly in the next week. The agency didn’t respond to a question about when those guidelines might be forthcoming.
Dental visits in a pandemic
Dentists say getting guidance as soon as possible about how to reopen their clinics is going to prove critical. Sandretti said it’s likely dentists will have to ramp up office cleaning, and utilize “virtual waiting rooms” where they would text patients about when to walk inside and straight to the examination room.
Patients likely would not be allowed inside if they show symptoms of COVID-19. Patients also might be asked to wear a mask throughout their visit except when their mouth is being worked on, she said.
Patients also won’t be seeing magazines in the office, and there will be limits on the number of items on counters and trays to make it easier to clean, she said.
“It is going to be pretty stark, Sandretti said.
But she said it’s important for dentists to return to work treating minor tooth ailments before they become major problems that send suffering patients to the emergency room.
“We have an important role in the community,” she said. “We keep patients out of the ERs. The last place I want a patient to go is the ER.”
Dentists struggle to find gear
After the governor’s office took back the masks from the stockpile, the dental association tried to negotiate to keep a few of them, but Stapler, the association’s vice president, said the state felt the masks would be better being distributed elsewhere, likely to municipal health organizations and the prison system.
The masks were expired, but officials believed that they would still provide protection for healthcare workers. Without the masks from the state’s stockpile, dentists scrambled to find a new supply.
“It was a pretty dire situation,” he said.
It hasn’t gotten much better in the weeks since. The state’s dental industry supply company has been forced to try to buy masks and other protective equipment on the open market, but it’s been extremely difficult to find reliable sellers.
“Finding a legitimate supply of PPE has proved to be virtually impossible,” Stapler said.
His association estimates that dentists would need to have 1.8 to 3 million masks — both N95s and regular surgical variety — per week. They’d be worn with reusable face shields, which can be cleaned between patients. The masks would need to be disposed of after each patient.
The association has asked for some of the masks from Newsom’s $1 billion deal with a Chinese manufacturer. There’s not been much luck there either, he said.
“From all we can tell, they’re getting those masks quite slowly as well,” Stapler said.
Since nearly all of California’s dentists are independent small business owners, who operate outside of the broader healthcare system they can’t fall back on large hospital chains to help bolster their supplies, Stapler said.
“So it’s a waiting game,” Stapler said. “And it’s a really unfortunate waiting game because we’ve got 36,000 dentists around the state who really would like to get back to practice.”