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SARS-CoV-2, known as COVID-19, has opened our eyes to the importance of planning for the unforeseen disasters that can affect our business operations. Not only has disaster and contingency planning surfaced as an integral part of business planning, but safety is now in the forefront. For the most part, business owners have never had to deal with the challenges that COVID-19 has created. In dentistry, the focus has been on bloodborne pathogens such as HIV, hepatitis B, and hepatitis C, but this is an airborne pathogen. Now is the time to look back at what has been learned from this experience and move forward to prepare for the possibility of a future occurrence.
The dental laboratory industry is no different as far as the impact COVID-19 has had on business operations. Many dental practices either closed or reverted to only emergency treatment, which affected the dental laboratories. Dental laboratories had to either shut down completely or to continue with minimal staff. Now most dental laboratories are back in operation and dealing with the challenges of protecting their employees. Many lessons have been learned from this pandemic as far as business operations. Communication among dental laboratory owners and their employees and dental clients can make or break providing a safe work environment.
In March 2020, the federal Occupational Safety and Health Administration (OSHA) published its Guidance on Preparing Workplaces for COVID-19.1 The purpose of this guidance is to help employers reduce the impact of this outbreak on their business, workers, customers, and the public. OSHA states that this guidance is intended for planning purposes and employers should use this guidance to identify risk levels in their workplace and determine appropriate control measures for implementation. The guidance document is advisory in nature and is not a standard or a regulation, but rather is intended to help employers be better prepared for the handling of this pandemic and any future epidemics or pandemics.
The above guidance from OSHA, however, says that states with OSHA plans can be more stringent than federal OSHA. An example is in Virginia, where the Virginia Occupational Safety and Health (VOSH) Program and Department of Labor and Industry issued on July 15, 2020, an Emergency Temporary Standard2 for Infectious Disease Prevention. The Standard took effect on July 27, 2020. Requirements were phased in during the period from July 27, 2020, to September 25, 2020. VOSH indicates in this standard that it is designed to supplement and enhance existing VOSH laws, rules, regulations, and standards that are directly applicable to SARS-CoV-2. This Standard will expire (i) within 6 months of its effective date or upon expiration of the Governor's State of Emergency, or when superseded by a permanent standard, whichever occurs first or (ii) when repealed by the Virginia Safety and Health Codes Board.
Business owners should take this opportunity to develop a robust health and safety program that considers the recommendations and requirements of OSHA. This will include an Infectious Disease Preparedness and Response Plan ("the Plan") that will become a part of the safety program.
Recommendations for the levels of risk that can be covered in the Plan include:
• Identification of possible exposures to workers including where, how, and sources of exposure;
• Policies to stay at home when sick;
• Return-to-work policies;
• Infection control procedures;
• Non-occupational risk factors at home and in the community; and
• Implementation of controls to address these risks.
Business owners must also stay abreast of their local, state, tribal, and/or territorial health agencies when establishing their policies.
Identifying and Managing Risks
First, laboratory managers should think through the development of the Plan by identifying the risks in their business. The risk areas to be considered are:
• picking up cases and delivering cases to dental clients.
• unpacking and decontaminating case components.
• repairing removable devices.
• exposing coworkers.
• allowing patients and visitors into the laboratory.
• providing chairside services.
• visiting dental clients for business develop- ment and customer service.
• dealing with exposures to COVID-19.
When the risks are identified, then OSHA directs an employer to consider-and implement when possible-engineering controls, administrative controls, and use of personal protective equipment. The following are some safety tips to protect employees who are performing the tasks identified as risks.
Picking up and delivering cases to dental clients
The risks to drivers who are employees involve entering a dental office to pick up or deliver cases. Since most dental practices are screening patients and visitors, the driver will go through the same screening procedure. The employer should contact the dental client to ask their procedures so that information can be shared with the drivers. Also, the dental laboratory owner or customer service agent should discuss the placement of the cases that are being picked up so the driver does not have to pass through treatment areas. Protection of drivers includes implementation of administrative controls and use of personal protective equipment (PPE).
For worker safety, these laboratories should:
• ask dental clients to place cases for pick-up in a location that does not involve the laboratory employee going into a treatment area or laboratory area in the practice.
• have pick-up personnel wear gloves to handle these items.
• instruct drivers how to dispose of gloves.
• instruct them to wash their hands frequently.
• provide hand sanitizer in the vehicle.
• provide disinfectant or disinfectant wipes.
• remind them to stay 6 feet away from people.
• write a procedure outlining how the driver decontaminates the vehicle.
Unpacking and decontaminating case components
The typical purpose of receiving in the dental laboratory is to unpack the cases, schedule the work, communicate with the dental client if additional information is needed, and decontaminate any potentially infectious items for handling throughout the manufacturing process. There are biological hazards during the unpacking and decontaminating procedures. These hazards existed prior to COVID-19; therefore, a dental laboratory that had effective procedures in place beforehand should reinforce the need for these employees to take precautions and wear their PPE. This PPE would include safety eyewear or a face shield, mask, gloves, and a gown. The gown must cover the street clothes to prevent contaminating them during this procedure. Also, the product used to decontaminate these items must be effective against human coronavirus.
The CDC has published information regarding how long this virus can remain active outside of the body, but that can change as time goes on and more is learned about this virus. The CDC indicates that this virus can survive for 24 hours on cardboard and other porous surfaces and for 2 to 3 days on hard surfaces. Most cases being picked up and shipped into the dental laboratory are packaged in a cardboard box, so this does leave some concern regarding their handling and re-use.
For safety:
• employees unpackaging cases should wear gloves; mask; gown; and safety eyewear or a face shield.
• do not leave this area until all PPE is removed and hands are washed thoroughly.
• disinfect everything these packages touch.
• dispose of the boxes and packaging or quar- antine for appropriate time.
• use decontamination products that claim effectiveness against human coronavirus on the label or have met EPA requirements for effectiveness against emerging pathogens.3
• check timing for effectiveness against human coronavirus or emerging pathogens and tuberculosis, as these can differ.
Repairing Removable Devices
Repairing and relining dentures in the dental laboratory introduces a biological hazard since the patient has been wearing this device. Even though the denture or partial is decontaminated upon receipt, as the removable technician grinds through the denture it can open surfaces that disinfectant did not reach in the initial disinfection. The best practice is to wear PPE to cover entry routes and street clothes while working on these devices. Wearing gloves may not be feasible when grinding, so washing hands or using alcohol-based hand sanitizers is needed.
Cleaning and sanitizing the work areas and equipment where the repair or reline has been performed are required to prevent cross-contamination with other devices. The pressure pot used for these repairs can also become contaminated, so take precautions to disinfect the pressure pot after processing of each repair. If the device can be placed in a container prior to placement in the pressure pot, that can help eliminate the need to disinfect the pressure pot between each repair or reline. For safety, ensure that these items have been disinfected upon receipt. Anyone handling these items must wear appropriate PPE; however, do not wear gloves when using rotary equipment. Lastly, decontaminate all equipment, work areas, and the pressure pot used on these items.
Exposing Coworkers
Employees need to understand the dental laboratory's policy for staying at home. Having a written policy allows employees to best understand the requirements established by their employer.
Any employees should be instructed to stay home when they:
• have a temperature higher than 100.3°F.
• have any respiratory symptoms including a cough or shortness of breath.
• have a reduced sense of smell and or taste.
• have been within 6 feet of a person with confirmed or suspected COVID-19 for 15 minutes or more within the past 14 days.
• are suspected of being infected with COVID-19.
• are confirmed to be infected with COVID-19.
• have participated in any risky behaviors, such as being in large gatherings where social distancing and mask-wearing are not fully observed.
Employees should be screened upon arrival at work. Measure the employee's temperature upon reporting to work and at any other time designated during the workday. Also, have the employee answer the following questions.
• Within the past 14 days has the employee encountered anyone with confirmed or suspected COVID-19 infection?
• Is the employee waiting on test results for COVID-19?
• Has the employee tested positive for COVID-19?
• Has the employee traveled to any area of the U.S. or another country that has had a high incidence rate of COVID-19 infections?
• Does the employee have any of the symptoms of COVID-19 infection?
If an employee has a temperature higher than 100.3°F and/or answers "yes" to any of the above questions, they will return home and seek medical attention. Document their temperature and their answers to the screening questions.
If employees develop any of these symptoms while at work, they should be sent home immediately and must follow the Return-to-Work policy that is established by the dental laboratory.
Allowing patients and visitors into the dental laboratory
It is best to limit access to the dental laboratory to only employees, patients, and others who may be providing services to the business. Help limit visitors by placing a sign on the front door informing visitors not to enter if they 1) have traveled within the past 30 days internationally or to an area in the US where there is a high incidence of COVID-19, 2) have been in the presence of anyone with confirmed COVID-19 or anyone who has been quarantined for the virus, 3) or have symptoms of COVID-19 (such as those symptoms for which employees are recommended to stay home). If they are allowed to enter the dental laboratory, take their temperature. Require all visitors to wear a mask; if they do not have a mask, provide it to them. Do not allow anyone to accompany a patient unless it is medically necessary. Employees who must greet the patient or visitor should maintain a 6-foot distance from them. Family members of employees should not enter the laboratory. Inform employees that if they are having someone picking them up or delivering to them to go outside to meet them, rather than having those people come into the office.
Do not become lax on the requirement that everyone entering the laboratory must wear a mask. This includes dentists and their staff who may need to visit. They should not expect that concessions will be made when it comes to their safety and the laboratory employees' safety.
Performing shade verifications in the laboratory
Laboratory managers need to communicate their visitation policy with dental clients who will send patients for shade verifications to the laboratory. Inform them that they must screen the patients and only send patients to the laboratory who pass the dentist's screening. When they arrive, take the patient's temperature, record it in their case information, and ask the patient the same screening questions as the employees. Maintain physical distancing of 6 feet whenever possible. The technician performing the shade verification should use full PPE, which includes mask, gloves, gown, safety eyewear, and face shield. Immediately after patient leaves, disinfect the area where the shade verification was performed. Inform dental clients that they must notify the laboratory if a patient who has been sent to the laboratory notifies the dentist after treatment that they are suspected or confirmed with COVID-19. Unfortunately, the laboratory will likely be the last thing the dentist thinks about when this occurs, so stay in touch with any dental clients and ask regularly whether any patients they sent to the laboratory have made this type of report.
At this time, many dental laboratory owners have ceased providing chairside services at dental practices due to the high risk to the technicians. Depending on the services to be provided by the technician, it could require the technician's presence in a treatment room where there are aerosols being generated. This would require the technician to wear a respirator, face shield, gloves, safety eyewear, and a gown. Employers must evaluate these risks and ensure that the technician is fully protected when entering this type of work environment. The employer must provide training on these risks, PPE to protect the technician, and inform the dental client of any policies established by the dental laboratory to protect its employee.
Prior to participating in any chairside services, it is important that the laboratory understand the expectations of the dental client regarding the extent of exposure to the technician during patient treatment. Discuss with the dentist the laboratory's infection control protocols for providing these services to the dentist. Also, inform the dental client that the laboratory must be notified immediately upon learning that a patient whom the laboratory's technician has been in treatment with is suspected or confirmed of having COVID-19. The laboratory must train the technician on the proper use and disposal of PPE; provide any appropriate PPE to technicians going to the dental practice (mask, gloves, gown, and safety eyewear or face shield); and supply them with disinfectant. If the technician will be present at the time of surgery, then an N95 respirator should be provided. Implement a Respiratory Protection Program that includes an evaluation of medical information and fit testing.4
Visiting dental clients for business development and customer service
During this pandemic, it is best to limit onsite visits to dental clients. Businesses have adapted to virtual meetings, so take advantage of that technology. When it is necessary for an employee to visit the dental client, ensure that they follow your safety protocols for physical distancing, wearing masks, and using hand sanitizers.
Dealing with Exposures to COVID-19
It is now a reality that exposures to COVID-19 are going to occur, so employers must be prepared to handle these situations. An employer has more control over their work environment; however, their employees can be exposed outside the workplace. OSHA requires employers to determine if an exposure to an employee is work-related.5
Establish written policies that include safe practices at work and provide continuing information regarding how important it is for employees to protect their coworkers by being just as safe outside of the workplace.
About the Author
Mary A. Bartlett President SafeLink Consulting, Inc.
References
1. OSHA 3990-03 2020 Guidance on Preparing Workplaces for COVID-19. https://www.osha.gov/Publications/OSHA3990.pdf. Published 2020. Accessed October 2, 2020.
2. 16 VAC25-220, Emergency Temporary Standard Infectious Disease Prevention: SARS-CoV-2 virus that causes COVID-19. Doli.virginia.gov. https://www.doli.virginia.gov/wp-content/uploads/2020/07/RIS-filed-RTD-Final-ETS-7.24.2020.pdf. Published July 15, 2020. Accessed October 2, 2020.
3. List N: Disinfectants for Coronavirus (COVID-19). US Environmental Protection Agency web site. https://www.epa.gov/pesticide-registration/list-n-disinfectants-coronavirus-covid-19. Published 2020. Accessed October 2, 2020.
4. OSHA 1910.134 Respiratory Protection Standard. OSHA United States. https://www.osha.gov/pls/oshaweb/owadisp show_document?p_id=12716&p_table=standards
5. Jillings LA, Kapust PJ. Revised Enforcement Guidance for Recording Cases of Coronavirus 2019 (COVID-19). https://www.osha.gov/memos/2020-05-19/revised-enforcement-guidance-recording-cases-coronavirus-disease-2019-covid-19. Accessed October 2, 2020.