By Anne Blythe
After closing for nearly two months for routine cleanings, North Carolina dentists are now opening up to a backlog of appointments.
At a recent meeting of the North Carolina Dental Board of Examiners, the eight members engaged in a spirited debate over whether to allow dentists across the state to oversee three hygienists instead of only two for the duration of the pandemic, in an effort to pare down the number of patients in the queue.
North Carolina has some of the country’s most restrictive scope of practice laws governing hygienists, one of which is limiting dentists to supervising only two hygienists at a time.
The emergency order in place for North Carolina now gives the dental board the ability to increase that number, but all members were not in agreement about when that should be done.
“With everything opening back up and we’re seeing an uptick in the number of cases, I don’t know that this would be a good time to do something like this … change to have more hygienists and more people in the office,” Buddy Wester, a Henderson dentist and board member who served as president at one point, said. “I think it’s dangerous.”
Catching up in a pandemic
Economists quoted in a recent New York Times article said dentists, whose business models are more stable than restaurants and other businesses hit hard during the pandemic, could provide just the barometer they need to try to figure out how the economy will bounce back from COVID-19.
If their businesses come back after the pauses in March, April and May, the economists said, and the patients come with them, then that might bode well for the country and financial recovery. Some offices are not at full tilt yet, in part, because hygienists and dentists who either have underlying risk factors or live with or care for someone who does are not returning.
Several board members from the larger practices advocated for expanding the number of hygienists one dentist may oversee so practices can catch up on routine cleanings and other screenings that had been scheduled for April and May but were postponed.
Raleigh Wright, chief of staff for Lane & Associates Family Dentistry and board member, pointed out that most offices are “back up to not normal speed, but some speed.”
Because of all the enhanced cleaning and infection-control steps taken between appointments now, hygienists are taking longer for each patient and seeing fewer of them.
Dentists and the hygienists who work alongside them have been described as workers in the very high exposure risk category for COVID-19 by the Centers for Disease Control and Prevention.
When the board issued new recommendations and guidelines in April, for how to open up and do more than emergency care as the pandemic wears on, it stopped short of codifying what measures dentists should take for infection-control and personal protective equipment. However, the board stressed that “failure to follow heightened infection control, sterilization, and patient safety recommendations may be viewed as a failure to meet the standard of care necessary for offering treatment during the COVID-19 pandemic.”
Hygienists raised concerns at the time, and the North Carolina Dental Hygienists’ Association amplified them and encouraged anyone troubled by their work environment to reach out for help.
“We understand your concerns and hear all the questions being asked,” according to a statement posted to the association’s website. “Ensuring your safety as a hygienist and the environment in which you will be working is the safest and healthiest place for you to be is our utmost priority.”
Struggle for single-provider offices
Some hygienists, for a variety of reasons, have not come back to work yet. Some offices have older dentists who have hesitated to work because of health risks, reducing the overall number of hygienists the practice can have because of the need for dental oversight.
“We have a situation where we have some young, healthy hygienists, but we have some older dentists who have decided not to come back quite yet so we’re running into a ratio problem from that perspective,” said Catherine Watkins, secretary-treasurer of the state dental board and a Winston-Salem dentist. “I don’t want to open up huge hygiene workshops or anything but I think maybe increasing in this time for one other hygienist for supervision under a dentist for this, I would be in support of that.”
Edward Clemons, a Durham dentist and board member, said he was worried about smaller practices like his being put at a disadvantage if larger practices could add more hygienists.
“We can’t even get the hygienists we need,” he said.
Wright said large practices were not immune to a hygienist shortage, and that’s presented a problem for patients trying to get appointments.
“Large group practices are having as big a trouble as you are to get hygienists,” Wright responded to Clemons. “They don’t want to come back to work right now, and the ones that don’t want to work full time. So that’s why, if you can get them to come in and add like a half a day even on a Saturday where you just do hygiene, that would enable practices to catch up.”
‘Let’s not rush it’
Wester echoed his concerns about COVID metrics and trends in North Carolina going the wrong way since easing of restrictions on May 22.
North Carolina has seen a sharper rise in the number of lab-confirmed cases of COVID-19, as well as a jump in the percentage of people being tested finding out they are infected. The number of people filling hospital beds with COVID-related illness has topped 900 this week, renewing questions about the capacity to handle a surge of new cases.
“We can’t be concerned with the economic situation of the dental practice,” Wester said. “We’re here to protect the public. While I’m sure that 90 percent of all dentists could run three hygienists and do it safely and just like we think it needs to be done, it’s the few, that, you know, are going to cut a corner here and there. They’re the ones I’m worried about. … It just puts more people in their office.”
“When things settle out, it may be something to do to get the backlog taken care of,” Wester added. “I just think with the uptick and what you’re seeing, it’s a little early, folks.”
Wright rebutted the assertion that asking for one more hygienist per dentist was only about the money.
“Ours is not a financial opportunity here. This is to enable us to catch up and allow patients to have their routine exams to diagnose decay, cancer, all sorts of things,” Wright said.
Wright also asked for any evidence that a dental office in North Carolina had been a source of COVID-19 spread, stating that he had not seen any.
“Well, because it’s early,” Wester responded. “… It’s the ones that are just going to run them in and run them out, and you add 50 percent with another hygienist, that’s the ones I’m concerned with.”
In the end, the board agreed to wait until July to take up the topic again.
“Let’s not rush it,” said Dominic Totman, a lawyer and the board member representing consumers. “Let’s give it another month and make a decision then.”
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As a new resident in the State of NC, I shutter at the archaic system under which dental hygienists practice here. Dental hygienists are first line providers in health promotion and disease prevention. The Board of Dentistry in NC is not concerned about patient care but the politics of controlling a profession not their own.