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Dental offices shut their doors to all but emergency patients when COVID-19 began spreading in March. Many dentists donated personal protective equipment (PPE) to local health care facilities desperate for the hard-to-find but crucial gear. But as dental offices around the country began to reopen for cleanings and fillings, dentists found themselves hunting scarce marketplaces for the protective gear they needed to keep their clients and staff safe and shore up their image of safety in a time when aerosols—tiny airborne droplets produced in countless numbers during a dental procedure—can be deadly.

The American Dental Association (ADA), the largest industry body, worked directly with the Federal Emergency Management Agency (FEMA) to have dentists declared essential health workers and included in FEMA’s PPE distribution plan. As early as June, dentists in need were receiving KN95 masks from the national stockpile. “Three months ago, we were in a much more dire position,” says Marko Vujicic, ADA chief economist and vice president.

The fact that they weren’t included at the outset rankled many. “‘Dentistry is essential health care’ is our latest motto,” says Kirk Norbo, a practicing dentist who is cochair of the ADA’s back to work committee. “For us to be looked at as nonessential and be at the whim of the next possible closure doesn’t help anybody.”

In a recent meeting, the ADA also threw its weight behind efforts to have dentists qualified to administer COVID-19 vaccines when such a thing exists—a role they have never held before.

Experts describe ongoing conflict, financial stress, and profound anxiety in the dental industry. While the industry has made an impressive recovery in recent months from a staggering 93% business downturn during the shutdown, these circumstances, they say, have only just begun to destabilize the industry.

Today, almost all of America’s dentists are back in the office, along with approximately 96% of their dental staff, who include hygienists, assistants, and office managers. Patients will likely notice some differences that have become all too familiar in the COVID-era world: enhanced PPE, prescreenings, and extra sanitation.

For the next few months, Vujicic anticipates a lull with about 80% of pre-COVID patient volume. The PPE situation has also stabilized, for now at least, with most dentists reporting a two-week supply. As most of the country heads into our first pandemic winter, he says, the short-term situation for dentists is fairly stable, both on the supply and the demand ends. After all, teeth are a notoriously troublesome aspect of human anatomy, and dental troubles don’t wait for a pandemic to end before they strike.

But change is coming. “I don’t see an imminent solution to the COVID problem,” Vujicic says. ADA projections show a 38% reduction in the dental industry overall for 2020 and up to a 20% reduction for 2021—assuming no major changes to the status quo over the winter. Given these figures, he says, the current volume of dental practices isn’t sustainable.

“Our latest analysis doesn’t paint such a rosy picture,” he says.

The backstory

This is the second time in the past 50 years that American dentistry has found itself dealing with public worry about safety caused by a virus. The last time, it was HIV. “That’s when dentistry made its first major transition in infection control,” says Michelle Lee, executive director of the Organization for Safety, Asepsis, and Prevention (OSAP), an organization that does research and education on dental industry hygiene.

“Since the ’80s, we’ve been following universal precautions,” Lee says. These precautions—masks and gloves during procedures, advanced air filtration, and sanitation—are credited with preventing the spread of human immunodeficiency virus, a blood-borne pathogen, through dental procedures. The dental industry made these changes in the context of several high-profile HIV infections related to dental care, which shook public confidence. Staff started treating every patient as if they might be infectious, preventing further infections and helping to resolve the crisis in public trust.

“Dealing with HIV was a real issue. Dentists took a lot of precautionary measures,” says Fred Leviton, president and CEO of the nonprofit Dental Lifeline Network.

Lee and others credit this ethos for being a major reason that dentists have been able to reopen with no COVID-19 infections to date being traced back to their offices. Although some of the precautions are new—no dentist ever wore a respirator in pre-COVID days, for instance—the mindset was already established, she says.

Even so, America’s dentists are facing a fresh crisis of trust, this time from their staff as well as their patients. Dental staff, asked to return to work in the midst of a pandemic after being furloughed or laid off, worried about whether they would be safe and whether they would bring the virus home to their families.

San Antonio dentist Joshua Austin authored a controversial editorial for a dentistry publication on this issue. In it, he called for dentists to keep in communication with their staff, and for hygienists, specifically, to raise concerns with their employer before blowing the whistle.

At his office, he says, “we had to have a sit-down meeting where we talked about what their concerns were, and I had to show them all the different things I was trying to do to mitigate them.”

Many of his friends who are dentists were having the same kinds of conversations, he says—especially with the dental hygienists they employ. “As a profession, they wanted to stay home and didn’t want to be out in what they perceived as a dangerous environment,” says Austin.

JoAnn Gurenlian, a professor of dental hygiene at Idaho State University and chair of the American Dental Hygienists’ Association (ADHA) back-to-work committee, tells it differently. Dentists and hygienists largely want the same thing, she says: safety for them and their patients. There was tension about coming back to work, but, she says, “it wasn’t really about conflict. It was about, How do we put all these pieces into play?”

The ADHA is still receiving hundreds of emails from hygienists concerned that their dentists are not observing the national recommendations leveled by the ADA, the ADHA, and the Centers for Disease Control (CDC), Gurenlian says.

“There was this really hard and quick reaction, and I think it really broke some major trust bridges,” says Tracy Anderson Butler, a former hygienist and dental industry consultant who spent a large part of her career advising dental practices on how to keep operations running smoothly and deal with interpersonal issues. She’s heard about bullying by both dentists and hygienists, she says, and workplace conflict over safety measures.

Most dentists are small-business owners as well as medical practitioners. They hire and retain their own staff, and they’re responsible for resolving these conflicts as well as overseeing the practice of hygienists and others. But hygienists, who are themselves trained medical professionals, can strike out on their own in some states, thanks to legislation that allows them to practice independently.

Both Anderson Butler and Gurenlian expect to see more hygienists taking this option, as well as some leaving the profession entirely. “I think it’s an awakening for dental hygiene,” says Gurenlian.

A short-term symptom of all this unrest is the fact that dentists are having trouble finding new staff and maintaining their existing staff right now. According to ADA numbers, roughly a quarter of dental practices were recently or currently looking to recruit hygienists or dental assistants but having a challenging time doing so.

Mitch Olan, executive chairman of Dental Care Alliance (DCA), says the pool of staff looking for positions has decreased during COVID. In the longer term, he’s hopeful that new graduates of dental care programs will fill those gaps.

Supply and demand

Then there’s the fact that one-fifth of demand for dental services has evaporated at a time when costs are going up.

“The short-term response I see coming is higher fees, layoffs, and potential exits among retirement-age dentists,” says Vujicic.

ADA numbers peg the additional costs of added PPE and sanitation at between $10 and $15 per patient visit. Sometimes that money is being recouped from insurers that are keen to see dentists stay in business, says Vujicic. Other times, although the ADA doesn’t know how often, dentists are eating that cost—for now. But in the medium term, he says, most dentists whom the ADA has asked say they’ll have to raise prices to account for their added costs, which means consumers would bear this additional cost.

Dental offices are keen to be seen as safe. During the pandemic, many people are just doing less of everything, concerned about the potential risks. Dentists rightly point out that no COVID-19 infection has been traced back to a dental office, but patients should be careful, just like with any other medical procedure at this strange time.

There’s a divide between how dentists talk and the recommendations of public health organizations. In August, the World Health Organization (WHO) released guidelines saying that routine dental care should be avoided in areas with community spread of COVID-19, and cases are rising in nearly every state across the country right now.

Then–ADA president Chad Gehani “respectfully yet strongly” disagreed in a release, saying, “With appropriate PPE, dental care should continue to be delivered during global pandemics or other disaster situations.”

This story is a microcosm of the public health back-and-forth that’s been characteristic of the conversation around dental care during the whole pandemic. What we know about SARS-CoV-2 has changed rapidly, along with public health recommendations of all kinds. And how the virus could spread in a dental setting is only beginning to be known.

An email survey of U.S. dentists conducted by the ADA earlier in the year reported an extremely low rate of COVID-19 infection among dentists themselves—under 1%—and universally enhanced protective measures were widely publicized by the organization. The research is ongoing and recently added hygienists.

But because there are so many asymptomatic COVID-19 infections out there and contact tracing has been difficult owing to such rampant public spread of the disease, it’s impossible to say how accurate the survey results are. That less than 1% stat from the ADA study might be an underestimate, the study author acknowledged—and that study only looked at dentists: It didn’t look at patients. But as for the more important question, whether dental offices are high-risk settings, the answer seems to be “no,” provided precautions are being taken.

More important, though, is that “not every practice is following guidance,” Gurenlian says. “Not every practice has enough PPE.”

Dentists are also eager to be seen as essential. The ADA adopted their new motto in a late-July meeting. The terms of their related policy broadly define essential dental care as “any care that prevents and eliminates infection, preserves the structure and function of teeth as well as the orofacial hard and soft tissues.” They recommended the term be used in advocacy instead of some previous terms: emergency dental care and elective dental care.

But the pandemic is demonstrating that if dental health is an essential part of health, and should remain open in emergency situations, it needs oversight mechanisms for the dental profession that mimic those for the medical profession. Gurenlian questions why those mechanisms, like an ability to report employers who aren’t observing proper hygiene procedures and industry-specific contact tracing, don’t exist for dental professionals. As it is, she says, “I think we need awareness of reporting to health departments and reporting to our national organizations.”

What comes next

The dental industry was already in the grips of change before the pandemic started. The old model of retailing dental supplies was slowly being abandoned in favor of shopping online, while the teledentistry sector was slowly growing, and a relatively new form of dental practice shaped by what are known as dental service organizations (DSOs) was also gaining ground. Industry watchers think all three are likely to become more prominent as a result of the pandemic shock to the industry.

When PPE shortages began, says Scott Drucker, a dentist turned online dental supplies retailer, dentists turned to traditional suppliers and found costs to be multiple times what they had previously anticipated or products to be simply unavailable. That got them looking farther afield, he says: “Many more dentists have found us now that they were pushed to shop elsewhere.”

Drucker’s company, Supply Clinic, is a marketplace with multiple retailers, but, he says, traditional distributors have also enhanced online stores in response to pandemic demand. “There’s been a large shift in the industry to online shopping,” he says. Beyond supply issues, there was also the fact that the traditional model, which involved a sales representative entering dental practices with samples and taking orders on the spot, isn’t really possible right now because of COVID-19 social distancing and space restrictions.

“There have been waves of spottiness in supply, and we’ve gone through waves of different items being difficult to procure,” Drucker says. First it was masks, then gowns, then disinfectant wipes. Now gloves are the hardest things to get hold of, he says. But with multiple opportunities to find supplies online and compare prices, dentists are more likely to get a good deal on the right product.

This process is the mirror image of a consumer transition that has destabilized traditional dental revenues. The Internet allows patients to shop around for well-reviewed dentists and compare dental prices, and it’s also made new forms of teledentistry—like SmileDirectClub, which produces clear aligners—possible. Drucker says teledentistry saw a short-term bump when dental offices were closed, but he doesn’t know if it that accelerated growth rate. However, both he and Olan think teledentistry’s market share will continue to grow.

Another trend that several people who spoke to Fortune believe will continue is the slow consolidation of the dental industry into larger practices and practices operated by dental service organizations (DSOs) like DCA, Olan’s group. These organizations are also known as dental support organizations.

Currently, 18% to 20% of dental practices are affiliated with DSOs. Technically, the dentists still own their practice, as is legally required, but they are part of a larger organization that oversees practice administration and marketing. Proponents of the DSO model, including Olan, say that partnership with a DSO allows dentists to focus on patient care rather than the business side of the practice. Detractors say that DSOs promote consolidation at the cost of patient care.

In the next five to 10 years, Olan expects DSO marketing penetration to increase by 30% to 35%. “The pandemic just added another layer of responsibility and stress on top of running a dental practice,” he says.

Dental students are graduating into a very different milieu than that of even a few years ago. “There’s no doubt that dental education in the future will be different from what it has been, because it is right now,” says Karen West, president and CEO of the American Dental Education Association.

Her organization has been closely tracking enrollment, and she says it’s currently on par with pre-COVID times. Dental students will graduate today with an average of about $300,000 in educational debt, Olan notes. He says many are unlikely to want to go the route of the sole practitioner. Their entry into the field will make its own mark on this changing industry.

For now, though, the dental business is in the eye of the storm, but you still might want to think about getting your teeth cleaned. As winter looms, Gurenlian says, “it’s more important than ever that we take extra care of ourselves.”