Dental hygienists worry about COVID-19 safety guidelines as clinics get set to reopen

As many shuttered dental clinics are preparing to reopen, a rift is growing in the industry over proper protocols to keep patients and staff safe — with one Ontario dental hygienist calling clinics a "ticking time bomb" for creating new COVID-19 cases.

After shutting down for all appointments except emergency services in mid-March, clinic owners now have Ontario's green light to start booking other procedures.

But how to do that safely is a matter of hot debate, with the latest guidelines from two regulatory bodies — one for dentists, one for dental hygienists — offering different road maps for team members working in close quarters in the same settings.

"If the recommendations are coming from science, should the science not be the same that they're looking at? Shouldn't the guidelines be the same?" questioned Lori Gallant, a long-time dental hygienist who owns a clinic in Pickering, Ont. and is keeping it closed for the foreseeable future.

Gallant and many other registered dental hygienists point to the most recent protocols for personal protective equipment outlined by the Royal College of Dental Surgeons of Ontario (RCDSO), the regulatory body for dentists, and those issued by the College of Dental Hygienists of Ontario (CDHO).

The CDHO stipulates dental hygienists should wear N95 respirator masks — the highest level of mask protection — for "all aerosol generating procedures," referring to the use of dental instruments which could release droplet particles from a patient's mouth.

The latest RCDSO guidelines, however, suggest wearing either an N95 mask or a lower level of protection like a surgical mask for any procedures generating aerosols.

"If you're working in the same environment, it's important that you're following the same stipulations," said Angela Fuller, a registered dental hygienist who works in two dentist-owned clinics in Scarborough and Brampton, Ont.

Debate over PPE usage

The RCDSO and CDHO both call for COVID-19 screening of all patients, using a series of questions provided by Ontario's Ministry of Health regarding someone's self-reported symptoms, travel history, and possible contacts with anyone infected.

But the regulatory bodies again differ on how to handle those screening results.

"Clients who screen positive must not attend the facility," the guidelines from the CDHO read.

Meanwhile the RCDSO allows people who screen positive to be treated at clinics "for emergency or urgent care" while dental professionals are wearing various levels of personal protective gear (PPE) — including an N95 mask for aerosol generating procedures, or just a surgical mask if those procedures aren't being used.

Gallant questioned if the province's screening questions go far enough to identify COVID-positive patients, since some people may be carrying the virus without showing symptoms. With that in mind, she said high levels of protection should always be worn as a precaution.

"We're talking mouth open, aerosols being produced," Gallant continued. "I don't understand why anything less than an N95 would be recommended."

So far, research into COVID-19 transmission has shown the virus likely spreads most easily in close quarters.

Several recent reports from the U.S. Centres for Disease Control, for instance, found high levels of transmission in multiple indoor settings with low ventilation over an extended period of time.

Given the potential risks involved in working so closely with patients, all dental professionals should be "treating everyone as if they're infected," said Irene Iancu, a registered dental hygienist who owns a clinic in Toronto.

"That helps us not only protect ourselves, but our clients and patients and their families."

Hygienists' guidelines too 'strict,' says dentist

Dr. Anna Banerji, an infectious disease expert and faculty lead for Indigenous and refugee health at the University of Toronto, said there is "validity" to dental hygienists' concerns amid growing evidence about how the illness spreads.

"COVID is a highly infectious virus ... nobody should be doing any procedure that is generating viruses in the air without an N95," she said.

In a statement provided to CBC News, RCDSO spokesperson Kevin Marsh said its latest guidance "reflects the recommendations of Public Health Ontario."

"Our guidance has been developed with input from a range of experts from different disciplines," he continued.

"Because the science is still evolving there are many opinions about what is needed for the safety of patients and dental office staff. We emphasize caution in any case where clear evidence has not yet been established."

But Lisa Taylor, CEO of the CDHO, said she understands why Ontario dental hygienists feel "concern and frustration" over the guidelines from another regulatory body.

Initially, both bodies actually took a similar approach, she noted. The latest RCDSO guidelines under fire this week were issued on May 31, and the CDHO was "not made aware" of the update in advance.

Dr. Phu-My Gep, a Toronto-based pediatric dentist, accused the CDHO of "playing on the public's fear."

Gep is behind an online petition with more than 1,700 signatures so far, which says the CDHO is "pitting hygienists against dentists." (Another online petition with more than 700 signatures is calling for a "collaborative approach.")

In an email exchange with CBC News, Gep called the college's guidelines "extremely strict." She added her own regulatory body revised its guidelines to adopt its current approach after a "backlash" about earlier protocols, which were more in line with what the hygienists' college is still mandating.

"The CDHO demands are unrealistic, especially in light of the shortage of PPE," Gep added.

Indeed, acquiring enough personal protective equipment is a concern for dental hygienists like Iancu, whose new clinic was supposed to open months ago but has remained closed since COVID-19 began spreading in Ontario.

Inside the brightly-lit space near the corner of Woodbine Avenue and Gerrard Street East in Toronto, she shows off the only two boxes of masks and gloves she has left after donating supplies to hospitals early on in the pandemic — since more rounds of protective gear are still on back order, she said.

Amid the challenges and debate, Iancu isn't sure when she'll ever be able to open, while Gallant is keeping the clinic she's operated for years shuttered by choice.

"You could be walking into a dental office where aerosols are produced," Gallant said.

"You're walking into a ticking time bomb."