In emails blasted to their patients, America's dentists are announcing their return from the coronavirus lockdown.
"WE ARE OPEN," was the all-caps heading for one email from a dentist in Miami.
"We are beyond ready to get back to work and see everyone that we have missed so much!" said another, from a dentist in Washington, D.C.
The emails were landing just days ahead of new guidance this week from the Centers for Disease Control and Prevention (CDC), which lays out public health and safety recommendations that allow for non-emergency dental care during the COVID-19 pandemic.
But as patients return and settle into reclining chairs with their mouths agape, dentists are confronting a unique set of new safety challenges and a significant pocket of resistance from some hygienists who never used to view their work as life-threatening.
"We work in a cloud of aerosol all day," said Luz Munera, a hygienist in Roselle Park, New Jersey, referring to the tiny airborne particles that can carry the virus and be spread by breathing, and circulated by dental and other medical procedures. "If the virus is still in the air, how is that next patient protected if they have their mouth open for an hour?"
'We're doing everything we can'
In 42 states, tens thousands of dentists are carefully transitioning to full-time work, with the help of safety and public relations advice from the American Dental Association.
Americans who struggled through weeks of stay-at-home orders and self-quarantine with toothaches might not recognize their dentist's office today, based on the ADA recommendations and some dentists with whom ABC News spoke.
In many offices, patients are screened for COVID-19 symptoms when they schedule an appointment, and have their temperatures checked on arrival. Waiting rooms have been cleared of chairs and magazines, and patients are encouraged to sit in their cars.
And everyone wears a face mask until a dental exam or cleaning has started. Dentists and hygienists will also be wearing goggles and face shields.
"We're doing everything we can do to provide a safe environment, not only for our staff, but for the patients when they show up," said Dr. Kirk Norbo, a Virginia dentist who reopened his practice to elective procedures on May 4, and helped write the ADA reopening guidelines.
The caution is justified: In normal times, dentists are among those medical professions most likely to be exposed to general disease and infection every day, according to data gathered by the Department of Labor.
Not only do they spend much of their time close to patients' mouths, but even the most routine procedures can produce aerosol particles and droplets - which linger in the air and can spread coronavirus from asymptomatic patients to anyone who sits in the same operating room.
Coronavirus can live in the air for several hours, and on some surfaces for several days, according to a recent study funded in part by the government and conducted by the National Institutes of Health and several universities. (The study has yet to be peer-reviewed.)
For some hygienists, who usually clean patients' teeth in dental offices, can spend more time with patients and statistically are even more likely to be exposed to disease, that danger has generated push-back.
Fears spark divide between some dentists, hygienists
In text message threads and on industry message boards, many have expressed concerns that the return is premature, and that some dental practices are not sufficiently prepared to protect dentists, their staff and patients from coronavirus.
"No dentist, no hygienist, no assistant, knowing what they know about aerosols, would feel comfortable putting one of their family members in a chair right now. Especially someone who is compromised," said one hygienist, who asked that their named not be used, saying they feared retribution.
Officials with the American Dental Hygienist Association, which represents more than 185,000 hygienists, said they are hearing those concerns. As of Friday, they recommended delaying non-urgent dental cases "until further notice," though the group said it is reviewing its position in light of the updated CDC guidance.
"The things we're hearing from members is just genuinely a concern about going back to work too soon and having the appropriate [protective equipment] available," Matt Crespin, the president of the hygienists' association, told ABC News, noting that members have said some dentists aren't abiding by the non-binding safety protocols.
Munera, the New Jersey hygienist, told ABC News that even though her employer took steps to protect his office - purchasing new air filters and suction equipment to minimize aerosol particles, in addition to wider use of masks and gowns - some other dentists are not. She said they are putting their staffs at risk.
Munera argued it could be more dangerous for some people to get their teeth cleaned than to get a haircut, if their dentist isn't taking the proper precautions.
"If a barber has a mask on and has a client come in for a haircut, and the client has a mask on, you can follow safety protocol," she said. "At the dentist, if safety protocol isn't maintained, you can't have a patient wear a mask and do a procedure."
Dentist: It's not about making people look good, it's about health
Dentists who spoke to ABC News about their practices defended the steps they have taken to reopen safely, and pointed to the new CDC guidance that allows for dentists to resume work while taking safety precautions, such as minimizing overlapping dental appointments and avoiding aerosol-generating procedures when possible.
Safety precautions should also be tailored to local conditions, and the scale of any coronavirus outbreaks in the dentists' communities, they said.
"The CDC has to make a guideline that goes basically to the lowest common denominator and the safest possible method for any or all situations," Dr. Tom Paumier, a dentist in Canton, Ohio, and former president of the Ohio Dental Association, who reopened his practice to non-emergency care in early May. "The reality is that if you're practicing in New York City it would be very different than Canton, Ohio, or anywhere else."
According to the CDC, no COVID-19 clusters have been reported in dental settings or among dental personnel.
Postponing elective dental care has health implications, too, said Dr. Philip Fijal, a dentist in the Chicago suburbs.
"We're not bleaching teeth. We're not putting veneers on teeth just to make people look better," he said. "We're trying to maintain their good oral health and take care of disease."
"There are outliers in every profession. No one's going to deny that," Dr. Mark Vitale, who practices in Edison, New Jersey, told ABC News. "But I think a lot of hygienists are fearful because of misinformation. And I think the professional organizations and the government need to get the correct information out there."
Vitale, a former president of the New Jersey Dental Association, pointed to the changes dentists implemented during the AIDS crisis - wearing gloves and face masks while seeing patients - as an example of the industry's ability to adapt to the current pandemic.
While he and his partner have stocked up on new face masks, gowns, cleaning materials and additional suction equipment to protect his staff and patients for any upcoming procedures, he called on the federal government to provide more protective equipment to dentists in the coming weeks.
"Do I think more research needs to be done on COVID-19? Absolutely," said Vitale. "It takes a long time to develop the vaccine or cure for it. But in the meantime you just can't shut down health care in the United States while you wait for the answers to your questions. You have to move forward."
Dentists and hygienists who spoke to ABC News agreed that patients need to be careful when scheduling visits to the dentist, and if possible, should ask about the precautions their office has put in place to prevent the spread of coronavirus.
Is their dentist screening patients and taking their temperature before seeing them? Are they spreading out appointments, instead of seeing multiple people at once? Are hygienists performing manual teeth cleanings, or using the tools that produce a lot of aerosol? Does the office have new air filter systems or suction equipment?
"Any question could be on the table with regard to the patient's right when they call my office," said Norbo, the Virginia dentist. "They're like a family member. So whatever they'd like to ask our front desk people when they call in, everything's on the table."
New guidance permits dentists to reopen, but some still harbor coronavirus fears
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