Update on COVID-19 and Dentistry
Dental practices have faced numerous challenges this year, due to the COVID-19 pandemic and those challenges continue. As the number of cases of COVID-19 continues to increase, dental practices are facing additional hardships. Supplies of PPE, especially respirators, continue to be difficult to find. Dentistry now faces shortages of disinfectant wipes and gloves. And as the community spread of COVID-19 increases, patients and dental team members are becoming infected in record numbers, causing confusion about what to do in case of exposure. Yet another challenge that looms on the horizon is increased surveillance of dental practices by regulatory authorities, such as OSHA and state dental boards. Managing these challenges requires dental teams to continue to access information updates from public health agencies, training when updates occur, and written documentation of efforts to provide the safest environment for both patients and dental teams.
There have been numerous OSHA inspections in dental practices resulting from complaints from employees. In addition, some state OSHA agencies have been conducting unannounced inspection for compliance with COVID-19 guidelines for employee safety. In the case of a practice in MA, OSHA issued numerous citations and fines of $9500.00. Information about this inspection is available through these links: Inspection Detail | Occupational Safety and Health Administration (osha.gov), and Georgetown Dentist Fined $9,500 For Violating Coronavirus Safety Guidelines – CBS Boston (cbslocal.com).
The good news is that vaccines should be available within the next few months. It is important to note, however, that the introduction of the COVID-19 vaccines will not immediately end the pandemic. Most public health experts agree that COVID-19 will continue to spread and require us to continue to follow our guidance from the CDC for at least the next year. We must continue to be vigilant in screening patients and employees, wearing appropriate PPE, practicing universal source control, updating infection prevention training and documenting all of the protocols that we follow to protect both patients and dental team members.
While it is unlikely that dental practices will be ordered to close again, as in the beginning of the pandemic, we cannot let pandemic fatigue to cause us to let our guard down. Instead it is an opportunity to fine tune our protocols to be prepared for whatever may come our way. Let us look at these protocols and what is required.
Both OSHA and the CDC state that when aerosol-generating procedures are performed, the respiratory protection level is N95 or higher. Guidance for Dental Settings | CDC and COVID-19 – Control and Prevention | Denstistry Workers and Employers | Occupational Safety and Health Administration (osha.gov). When N95 masks were very difficult to find in the beginning of the pandemic, the FDA allowed the use of Chinese-approved KN95 respirators to be used during the pandemic through its Emergency Use Authorization (EUA) provisions. In addition, when even the KN95 respirators were difficult to obtain, the CDC guidance stated that an ASTM Level 3 surgical mask and a full face shield could be work, but not for treating a patient that known or suspected to be COVID-19 positive. Although N95 respirators are still not in great supply, they are available now through both dental and medical distributers. Respirator manufacturers have increased production and shifted production to the U.S. to assist in getting these much- needed devices to health care professionals. In addition, the FDA EUA allows health care workers to reuse these disposable (one-time use) devices to help supplies to last longer.
It is risky to assume that just because respirators were difficult or impossible to obtain several months ago, that may not be the case now. If your practice is inspected by OSHA, an inspector will ask to see documentation of your attempts to obtain appropriate PPE. Keeping a log of these efforts will protect your practice against citations and fines.
There have been news reports of severe shortages of gloves. This could be a game changer. Unlike respirators during the EUA, gloves cannot be reused. Practices may have to switch from their preferred type or brand of gloves temporarily, even using latex gloves in some cases. Latex gloves have not been used routinely for some time because of the prevalence of sensitivity and allergies on the part of patients and dental professionals. If you must use latex gloves, be sure to screen both patients and employees for these sensitivities and make sure that your Epi-Pens are accessible and up to date in case there is an emergency.
Many dental distributers are providing different brands of disinfectant wipes than what most practices are familiar with. Make sure that the product is EPA registered, and has a label claim as a tuberculocidal disinfectant. Although many manufacturers are promoting their EPA-registered claims against SARS-CoV2, the CDC Guidelines for Infection Control in Health-Care Settings states when there is the presence of blood, an intermediate level, tuberculocidal disinfectant must be used. RR5217 Dental Front.pmd (cdc.gov).
The EPA stated early in the pandemic that products on the EPA List N should be used, but recently clarified that if a product does not appear on this list, but has a label claim for a microorganism more difficult to kill than SARS-CoV-2, it was acceptable to use. List N Advanced Search Page: Disinfectants for Coronavirus (COVID-19) | Pesticide Registration | US EPA.
It is possible that your favorite brand of disinfectant is available in a liquid formula that can be applied with a spray bottle, however, it is important to remember that we switched from spraying disinfectants to using wipes to decrease chemical exposure (and potential for respiratory problems) for dental team members. The solution can be sprayed onto an applicator (gauze or paper towel) and applied to surfaces. The CDC Guidelines for Sterilization and Disinfection in Health Care Settings Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 (cdc.gov) state that solution should not be placed in containers where gauze or other applicators is soaked. The fibers in the gauze will inactivate the solution. Wipes are different in composition and do not cause this to happen. Several companies, including SciCan, sell dry wipes (StatWipes) that you can add your preferred disinfectant to.
In addition to an OSHA-required Exposure Control (infection control) Plan, dental practices must also have a COVID-19 Preparedness and Response Plan. This must be in writing and is a key document scrutinized in an OSHA inspection. Key elements of this plan include a Hazard Assessment and Exposure Determination, and protocols to follow if an employee is exposed to COVID-19 at work. Guidance for the Preparedness and Response plan is available from OSHA in these documents: https://www.osha.gov/Publications/OSHA4045.pdf and Guidance on Preparing Workplaces for COVID-19 (osha.gov). CDC guidance on exposure to COVID-19 and returning to work is available in these documents: Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19 | CDC,
When dental team members wear respirators, a written respiratory protection plan is also required, which includes information on the required medical evaluations and fit testing of the devices. Again, OSHA has provided guidance on developing a plan in these links and documents: https://www.osha.gov/Publications/OSHA3990.pdf, OSHA 3384 SMALL ENTITY FOR RESPIRATORY PROTECTION STANDARD REV 9.28.11:Layout 1. Medical evaluations and fit testing must be documented. Although it has been reported that OSHA has suspended all fit-testing requirements, it has only suspended the annual fit-testing of respirators. These tests must be completed initially (when first wearing respirators) and any time that the type or brand of respirator is changed. Since this could be often, due to supply shortages, I recommend that dental practices conduct their own fit-tests. A member of the team can be trained to administer the fit-test and test kits can be purchased through most dental distributors. Some test kits come with an instructional video, but online training is available and there is no certification required. A free, online program for fit-testing is available through the American Association of Occupational Health Nurses at: AAOHN : Online Learning.
Dentistry will be forever changed by this pandemic – mostly in positive ways. We have a better understanding of disease transmission and how to control the spread of infectious diseases. We have more scientific knowledge about the hazards of exposure to aerosols in dentistry and the importance of air quality in our dental health care settings. Our patients have a greater appreciation for all the safety protocols we follow to keep them safe. The negative impact is most certainly from the costs associated with PPE and other equipment and supplies. But we are dedicated to the delivery of quality oral health care in the safest manner possible. We will survive this challenge and quite possibly be more resilient because of it and be better prepared if another pandemic occurs in the future.
Mary Govoni, MBA, CDA, RDH
Mary Govoni & Associates