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While the CDC has not made a definitive statement about how exactly COVID-19 can and cannot be transmitted, studies indicate that human coronaviruses in general can persist on inanimate surfaces such as metal, glass, or plastic for up to 9 days if not inactivated via surface disinfection procedures.1
As such, the author's consulting firm has issued guidance to dental laboratories suggesting that they require any offshore partner laboratories to disinfect restorations prior to shipping-something that is not standard practice and even in the US is required in only two states-and note it with a sticker on the package. The author believes it is incumbent upon any US laboratory importing from another country to inquire of that offshore laboratory whether it is disinfecting, and if not, to consider requiring it. Make sure that laboratory has met the criteria published by the Environmental Protection Agency regarding emerging viral pathogens.
Of course, with the virus continuing to spread in the US, person-to-person transmission is a concern for dental laboratories as well.
To guard against the possibility of an employee inadvertently introducing the virus into the laboratory, the author recommends reviewing the CDC's 2003 infection control guidelines for dentistry and the summary published in 2016.2
This ebook will focus on the issues to be addressed by employers in the development of an effective infection prevention program based on those CDC guidelines. The 2016 CDC Summary is broken down into six areas of fundamental elements needed to prevent transmission of infectious agents in dental settings:
1. Administrative Measures
2. Infection Prevention Education and Training
3. Dental Health Care Personnel Safety
4. Program Evaluation
5. Standard Precautions
6. Dental Unit Water Quality
The Summary also includes Appendix A, which is an Infection Prevention Checklist for Dental Settings: Basic Expectations for Safe Care. This should be used to develop a checklist specific to the facility and program that is being evaluated. Appendix B provides relevant recommendations for dental infection prevention and control published by the CDC since the 2003 Guidelines. It includes:
• Infection prevention program administrative measures
• Infection prevention education and training
• Respiratory hygiene and cough etiquette
• Updated safe injection practices
• Administrative measures for instrument processing.
1. Develop and maintain infection prevention and occupational health programs: OSHA's Bloodborne Pathogens Standard (BPS) requires employers to develop an Exposure Control Plan (Plan). This Plan describes the risk areas in the laboratory, and how employees will be protected through controls such as administrative and engineering, as well as through the use of personal protective equipment. It also indicates the person in the facility who is responsible for providing protective equipment, training workers, and monitoring the infection prevention controls. Annually this Plan must be assessed to ensure that the controls are being followed by workers in risk areas and those individuals who are responsible for administering the components of the Plan. This annual assessment should be documented.
2. Provide supplies necessary for adherence to Standard Precautions: These supplies include hand-hygiene products, safer devices to reduce percutaneous injuries, and personal protective equipment. In a dental laboratory the use of hand-hygiene products for infection prevention would be applicable in the receiving area, model room, denture repair areas, and shade verification area. Further information on this prevention method will be discussed under Standard Precautions.
3. Assign one individual with training in infection prevention: In most workplaces the Safety Coordinator or Safety Officer is responsible for administration of the health and safety program. In a dental laboratory, this individual's knowledge of chemical hygiene, infection control, environmental hazards, and emergency planning can all be included in the scope of the position. The Summary recommends that at least one individual with training in infection prevention be responsible for developing the written infection prevention policies and procedures based on evidence-based guidelines, regulations, or standards. The employer is responsible for providing the training that is necessary for this individual to be knowledgeable in all phases of infection prevention that are applicable to the employer's workplace.
4. Develop and maintain written infection prevention policies and procedures: These policies and procedures must be appropriate for the services provided by the facility and based on evidence-based guidelines, regulations, or standards. Development of an infection prevention program begins with an assessment of the hazards. In a dental laboratory, the assessment starts with the incoming work from dental clients. The BPS requires the employer to protect its workers; therefore, presuming that the dental client's staff disinfected the items prior to shipment is not sufficient worker protection. All items that can withstand disinfection must be disinfected upon receipt and handled by workers downstream of the Receiving Area. Disinfection doesn't stop at that point. If the assessment determines that workers can be exposed in other areas of the laboratory, then infection prevention controls must be developed and implemented.
5. Employer must have a system in place for early detection and management of potentially infectious persons at initial points of patient encounter: In a dental practice there would be more extensive controls for these purposes. In the dental laboratory, there would be patient encounters when dental technicians perform services at the dental practice and when patient shade verifications involve the actual patient at the dental laboratory.
Infection Prevention Education and Training
Infection prevention training must be specific to the job or task being performed. Workers must be trained upon hire, when new tasks or procedures are introduced, and at a minimum annually. This training includes temporary workers, contract workers, and volunteers. A dental laboratory also must train dental technicians who will be performing services in the dental client's facility and ensure that the dental technician understands the infection prevention policies for the specific dental practice.
Dental Health Care Personnel Training
The infection prevention program should address occupational health needs that include vaccination of dental health care personnel, management of exposure or infections that require post-exposure prophylaxis or work restrictions, and compliance with OSHA's BPS.
There may be more extensive vaccination requirements in dental practices, but in dental laboratories employers must offer the Hepatitis B vaccine to workers in risk areas. As stated above in Item 1 of Administrative Measures, the Exposure Control Plan requires assessment of risk areas. Workers in those risk areas must be offered the Hepatitis B vaccine within 10 days of hire or job assignment should their job change from the initial hire. The employer's responsibility is to educate the worker on the risks and then offer the Hepatitis B vaccine. If the worker declines the vaccine for any reason, then the employer must have the worker sign a Refusal form. Should the worker change his or her mind after the initial offering, then the employer would provide the vaccine and keep a record of the immunizations.
In a dental laboratory, an employer may offer other vaccines to workers; however, currently just the Hepatitis B vaccine is required by OSHA.
Post-Exposure Evaluation and Follow-up is required by OSHA in the BPS. Whenever a worker is exposed to body fluids by a cut or splash/splatter into the body, then the employer must follow the Post-Exposure requirements. This procedure requires the employer to offer the affected employee blood testing. The worker can decline this offer; however, the employer must document this offer on OSHA's Post-Exposure Evaluation and Follow-up form. It is then the duty of the employer to contact the dental client to inform them of the exposure incident, and ask the dental client to request for the patient to consent to testing. The consent or denial of the dental client and/or patient will also be documented on the Post Exposure form. Results of the testing will be kept confidential by the employer and released to the employee. Follow-up consultation for the employee will be provided by the employer as needed.
The Summary reaffirms Standard Precautions as the foundation for preventing transmission of infectious agents. OSHA refers to Universal Precautions; however, the CDC refers to Standard Precautions as the minimum infection prevention practices.
Universal Precautions are defined by OSHA as "an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens."
The CDC refers to Standard Precautions as representing "the minimum infection prevention measures that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. These evidence-based practices are designed to both protect health care personnel and prevent the spread of infections among patients. Standard Precautions replaces earlier guidance relating to Universal Precautions and Body Substance Isolation. Standard Precautions include: 1) hand hygiene; 2) use of personal protective equipment (eg, gloves, gowns, facemasks), depending on the anticipated exposure; 3) respiratory hygiene and cough etiquette; 4) safe injection practices; and 5) safe handling of potentially contaminated equipment or surfaces in the patient environment."3
Dental Unit Water Quality
This part of the Summary discusses how dental unit waterlines can promote bacterial growth and the development of biofilm in the plastic tubing that carries water to the high-speed handpieces, air/water syringe, and ultrasonic scaler. The CDC recommendations are to:
1. Use water that meets EPA regulatory standards for drinking water.
2. Consult with the dental unit manufacturer for the appropriate methods to use on the equipment to maintain the quality of the dental water.
3. Follow the manufacturer's guidelines or the waterline treatment product for monitoring the water quality.
4. Use sterile saline or sterile water when performing surgical procedures.
Beyond the CDC Guidelines: Patient Interaction
One possibility for person-to-person contact that is less predictable is patient interaction. While the CDC has provided suggested screening questions for dental offices to ask patients, dental laboratories are not permitted under HIPAA to ask those questions directly. Thus, the laboratory must rely on the dentist when sending a technician to work chairside or hosting a patient for shade verification services.
The author's opinion is that the dental laboratory should be assured by the dentist that any patients being sent to the laboratory for a shade verification or for any other reason have been screened. For chairside services, which are becoming increasingly common, the laboratory owner has always been responsible for the technician who is being sent into the dental practice. The dentist is also responsible for protecting them. Either the dentist needs to provide the personal protective equipment to that technician, or the employer needs to provide it to ensure that they are following standard and universal precautions while that technician is in the dental practice.
Of course, these precautions are not completely foolproof, especially with a virus that has been shown to be contagious even when no symptoms are present. Some laboratories may want to discontinue direct patient services for the time being if they or their own employees are concerned.
About the Author
Mary Borg-Bartlett is the Co-founder and President of SafeLink Consulting Inc. Since 1991, Mary has actively participated as a presenter and on-site instructor to audiences of dentists, dental hygienists, dental assistants, and dental laboratory technicians throughout the US. Prior to founding Safelink, Mary held senior level management positions in mortgage banking, banking, and the family entertainment business. Her positions included responsibility for Facilities Management, Human Resources, Risk Management, Crisis and Disaster Recovery, and Health and Safety.
1. Kampf G, Todt D, Pfaender S, and Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. Journal of Hospital Infection. 2020;104(3): 246-251.
2. Borg-Bartlett MA. Updated Guide to Basic Infection Prevention Practices. Inside Dental Technology. 2016;7(10):26-31.
3. Basic Infection Control and Prevention Plan for Outpatient Oncology Settings. Centers for Disease Control and Prevention Website. http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/fundamental-of-infection-prevention.html. Accessed August 19, 2016.