Add to the toll of COVID-19 oral health.

“Tooth pain and periodontal abscesses and face swelling,” said Kari Hexem, chief dental officer at Philadelphia FIGHT Family Dentistry, in Center City, listing some of the conditions that have worsened in people who avoided the dentist for more than a year due to fear of COVID-19.

“Some people lost teeth they wouldn’t have lost if they had come in,” said Bernadette Logan, a suburban dentist at Paoli Smiles. “Definitely harder cleans, more tartar, broken teeth.”

She didn’t see about 25% of her regular patients during the pandemic, she said.

Dentists are also seeing patients with signs of teeth grinding and clenching, likely the results of pandemic-related stress.

Dental offices, like their long-absent patients, are struggling, finding themselves understaffed and financially stressed just as people are clamoring for appointments.

Reduced staff and increased safety protocols due to COVID-19 mean fewer patients can be accommodated. In January 2020, Hexem said, her practice saw 548 patients in-person. A year later, that number was down to 325. It’s a national trend, with just over 38% of all dentists seeing fewer patients than before the pandemic, according to a May 17 survey conducted by the American Dental Association’s Health Policy Institute.

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Dentists are raising fees, taking out loans, or cutting expenses, including by curtailing their hours or farming out tests to cheaper labs, said Linda Himmelberger, a retired Chester County dentist and a trustee for the ADA, to cope with the combination of fewer patients and higher costs.

“They’re working up to capacity,” she said. “They’re booked, but because of all the additional disinfection procedures and can’t have overlapping people in the waiting room, the volume is decreased.”

Which means patients who aren’t in crisis may wait weeks or even months for appointments.

Pandemic shutdown

At the beginning of the pandemic, a governor’s order shuttered most Pennsylvania dental offices except for emergency procedures from late March to early May 2020. Dental care presented a serious risk of COVID-19 transmission, public health experts and dentists said, because so many procedures, even the simple swirling of a brush in a cleaning, create aerosols.

“We knew that the virus was transmitted by aerosols,” Himmelberger said, “but nobody knew exactly what the mechanism was or what we needed to do to keep ourselves, our staff, and our patients safe.”

About 76% of Pennsylvania’s dental offices closed except for emergencies during that period, she said, and 19% closed entirely. The ADA estimated more than 1% of Pennsylvania’s dental offices remain closed.

“It was definitely scary,” said Wilson Chan, a dentist at the Philadelphia FIGHT office. “The first week going back, when things were more in the unknown, I had to numb a patient up. She was in a lot of pain, and just during that procedure I could feel her breath, her warm breath, in my face.”

One day he treated a pregnant patient, dreading the possibility that he could unknowingly infect her with the coronavirus.

Ventilation changes and an investment in masks, face shields, and other protective equipment proved effective, but staff who left the field entirely in the interim have proven hard to replace.

“The staffing issue now is in a crisis situation,” said Amid Ismail, dean of Temple University’s Kornberg School of Dentistry.

Hygienists, dental assistants, and expanded function dental assistants quit or retired during the pandemic, dentists in the region said. Hygienists are primarily responsible for cleanings, and dental assistants offer essential support for dentists performing procedures. Expanded functions dental assistants, or EFDAs, are trained to aid dentists with more specialized procedures.

“There are procedures that require four hands,” Ismail said, “not two hands.”

The American Dental Hygienists’ Association estimated dental offices nationwide have lost about 8% of hygienists.

“Hygiene was the worst position to have during the pandemic,” said Mackenzie Hubing, a hygienist in the Philadelphia FIGHT office. “It was the closest proximity to patients and for the longest duration. I was terrified when COVID first came out.”

She stayed on the job, she said, because she trusted Hexem and her office, which installed three negative pressure rooms for dental procedures, a ventilation control solution more comprehensive than what many other offices have done. She has friends, though, who abandoned the profession.

The ADHA survey found fear of COVID-19 was a major impetus for departures. The lack of child care was also a factor. Now, dentists offices’ protective measures -- needed because not everyone is vaccinated -- make the job more uncomfortable.

“It’s hard to breathe. It’s harder to see,” said Logan. “It definitely takes longer to do things.”

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Susan Cole, a hygienist in Logan’s office, retired after 26 years for that reason, she said.

“I personally knew I would have a difficult time wearing an N95 mask and goggles and a face shield and a surgical cap and my scrubs and a full length, long sleeve surgical gown on top of that,” she said.

She is planning to move to Florida in July, she said, to be closer to family, and likely will not work again as a hygienist.

A workforce in demand

Hexem, Ismail, and Logan are all trying to hire. Dental assistants expect up to 20% more than they were making pre-pandemic, Ismail said, a particular strain for nonprofits like Philadelphia FIGHT.

Many of Hexem’s patients are on Medicaid, underinsured, or uninsured, and rely on the office, no matter how long the wait may be. She’s adapted to the realities of COVID-19 by offering some virtual sessions with patients, something she expects will continue to be a valuable tool, and, more recently, training staff to administer COVID-19 vaccines; she said 90% of her patients are vaccinated. Inoculation isn’t mandatory for staff, she said, but she would far rather work with those who are.

Hexem boosted dental assistant pay by $2 an hour, with those who can offer expanded functions commanding an extra $4. She’s concerned that one of her hygienists is being wooed by another office able to pay more.

While trying to boost her capacity to see patients, she said, she faces daily a list of patients who are eager to return to their regular six-month appointments.

“We’re not able to offer that yet,” she said, “but we are trying to reach out to our patients who were on that schedule and start getting them back in.”

This story has been updated to correctly attribute a quote to Mackenzie Hubing.