By Mary Govoni, MBA, CDA, RDH
Dental practices across the country have been dealing with the effects of the COVID-19 pandemic. First was the trauma of closing the practice, except for emergency patients. Next was playing the waiting game of how long the practice would be required to stay closed. And now, every practice is having to cope with new patient and employee screening protocols, additional PPE and its associated expense, as well as myriad issues related to scheduling, mitigating aerosol production, fearful patients and employees. I cannot think of a more challenging time to be a dental professional than this year.
The most frequent complaint I hear is that the information being circulated about infection prevention and dentistry is confusing. We heard “guidance” from the CDC and the ADA, and OSHA. We also have OSHA regulations that we must follow. In some cases, state dental boards and public health agencies are issuing guidelines, regulations and information updates. Sadly, the confusion is caused by the fact that some of the information is conflicting. How do we know what to do, and to whom are we are accountable?
The answer to this question is relatively simple. Regulatory agencies’ rules and regulations must be followed. Regulatory agencies include OSHA, state dental boards, state health departments, and the federal Food and Drug Administration. Membership organizations, such as the ADA and ADHA are not regulatory agencies. These and other groups should issue guidance to their constituencies, but it is not legally binding. Although guidance from the ADA and other organizations is most often aligned with OSHA standards and CDC guidelines, there have been recent instances where it has not been. For example, the ADA states in its Return to Work Interim Guidance Toolkit that OSHA has suspended the “fit testing” requirements for N95 respirators. In fact, OSHA has suspended only the annual “fit testing” requirement, not initial “fit testing.”” If a dental practice were inspected by OSHA, the dentist/employer could be subject to a citation and fine for not complying with the OSHA PPE rules. More on “fit testing” later.
The COVID-19 crisis has brought CDC guidelines very much into focus for dentistry, and my hope is that they will now get the respect and emphasis that they should have had up to now; here is why; OSHA uses CDC guidelines for their enforcement guidance, especially in the area of infection control. Additionally, many state dental boards require dentists, assistants and hygienists to comply with CDC guidelines as the established standards of care for infection control and prevention. In this time of tremendous media coverage, the CDC has been constantly mentioned in news reports. Also, the CDC website has experienced increased traffic on its website, exposing the general public to the vast amount of information—including guidelines for infection prevention and control in dentistry. This has created a higher level of awareness of the CDC’s guidelines and a new level of expectation about infection prevention and control from patients receiving oral health care.
So, having said all that, it is important to remember that the current CDC guidance is temporary—in effect for the duration of the pandemic. The CDC states that it will continue to update this guidance as more data becomes available, such as statistics on COVID-19 cases, and disinfection protocols. Dental professionals should monitor the CDC Coronavirus information page and all of the applicable links: https://www.cdc.gov/coronavirus/2019-nCoV/index.html, as well as the section with information pertaining to dentistry: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html.
OSHA’s COVID-19 guidance is also interim: https://www.osha.gov/SLTC/covid-19/dentistry.html, and https://www.osha.gov/Publications/OSHA4019.pdf, however, the previously existing Bloodborne Pathogens Standard remains in effect, as well as the OSHA Bloodborne Pathogens Standard: https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030, the Hazard Communication Standard: https://www.osha.gov/dsg/hazcom/, and the PPE Standard: https://www.osha.gov/SLTC/personalprotectiveequipment/standards.html.
One additional standard that is not as well known in dentistry is the Respiratory Protection Standard: https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134. Every dental practice and the practice’s OSHA manager should have copies of these standards and familiarize themselves with them. The OSHA Respiratory Protection Standard mandates any business whose employees are required to wear respirators (such as N95 respirators) have a written respiratory protection program. This should include “fit testing” and medical evaluations for employees to determine whether the employee can safely wear a respirator. The “fit testing” (initially and annually) is required to make sure that the respirator fits correctly and provides the employee the maximum protection against safety hazards in the workplace. In dentistry this hazard is aerosols.
Aerosols are generated whenever a dental practice uses high-speed handpieces, air/water syringes, ultrasonic scalers and air abrasion/polishing devices. The aerosol issue is what has prompted OSHA to create two new risk categories for dental professionals, which are “high” and “very high” risk. The table below details all the levels of risk in dentistry, according to OSHA.
In addition, OSHA lists the PPE requirements for the corresponding risk categories in the table below.
As listed above, when aerosol-generating procedures are performed on patients, N95 respirators, or higher levels of protection, are recommended. The CDC guidelines state the same recommendation. Respirators provide a higher level of protection than surgical masks, because the respirators form a seal on the face, preventing aerosols from getting in on the gaps on the sides, top and bottom of a surgical mask.
There are groups and individuals that question the use of the word “recommended,” as opposed to “required.” Since this virus is very easy to transmit, there are still so many unknowns, and we do not know who may be infectious; it only seems to make sense to follow this recommendation. This is especially important considering the data that shows that pre-symptomatic individuals appear to have the highest SARS-CoV-2 viral load and are therefore the most infectious.
Many practices have had problems obtaining N95 respirators. However, that shortage is beginning to ease. The expense of the respirators, coupled with the difficulty procuring them, has prompted some practices to search for alternatives for respiratory protection. These include KN95 respirators, not certified by the National Institute for Occupational Safety and Health (NIOSH) or cleared by the FDA. These respirators are allowable for use in U.S. in health care settings under the FDA’s Emergency Use Authorization because of shortages that occurred in the early states of the pandemic. Many of the masks have been discovered to be counterfeit, and most are not true respirators. A respirator must have two head straps, not ear loops. ASTM level 3 facemasks are the other alternative that many practices have selected. However, level-3 ear loop masks are not considered surgical masks, as referenced in the CDC guidance. A surgical mask is one that has two ties, one that goes on top of the head and one that ties at the back of the neck. This configuration helps to prevent gapping on the sides of the mask.
It is frustrating and fearsome to hear dental professionals not taking the threat of exposure to aerosol production in dentistry seriously. It is also frustrating to hear that many dental professionals would rather accept respiratory protection that is less than optimal in their haste to reopen their practices. While I completely understand the financial impact that this pandemic has had on practices, the financial impact of a doctor or team member being exposed to or developing a COVID-19 infection is even greater.
Another frustration is the number of “alternative” methodologies that are being circulated about reuse of respirators and face masks. These include placing them in an autoclave, spraying with disinfectant, and using non-FDA cleared UV light units for decontamination. When respirators or masks get wet, they become ineffective, which puts the user at greater risk when reusing the items. It is risky to use these alternative methods that are not recommended by OSHA or the CDC. There is increased liability to an employer who does not follow proven methods for protecting employees from exposure.
When public health is at risk, follow standards and guidelines. Also follow the science—make sure your protocols and devices are validated. As dental professionals we should always be dedicated to doing the right thing for patients and the dental team.
Mary Govoni, MBA, CDA, RDH
Mary Govoni is an internationally recognized speaker, author and consultant who has specialized in infection prevention and OSHA compliance for over 25 years. Mary is an authorized OSHA Outreach Trainer who assists teams achieving compliance with standards and guidelines to create a safe environment for both patients and team members. She is known for her practical approach to compliance, which comes from her many years of clinical experience as a dental assistant and hygienist.