Dentistry Workers and Employers - Steps to Stay Safe
- Posted on Tuesday, May 5, 2020
Dentistry Workers and Employers
This section provides guidance for dentistry workers and employers. This guidance supplements the general interim guidance for workers and employers of workers at increased risk of occupational exposure to SARS-CoV-2.
On March 16, 2020, the American Dental Association called for dentists to keep their offices closed to all but urgent and emergency procedures during the COVID-19 outbreak. Unless emergency dental procedures absolutely cannot be delayed, OSHA further recommends that emergency dental procedures be performed on patients with suspected or confirmed COVID-19 only if appropriate precautions, including personal protective equipment (PPE), are available and used.
Employers should remain alert of changing outbreak conditions, including as they relate to community spread of the virus and testing availability, and implement infection prevention measures accordingly. As states or regions satisfy the gating criteria to progress through the phases of the guidelines for Opening up America Again, employers will likely be able to adapt this guidance to better suit evolving risk levels and necessary control measures in their workplaces.
Employers should assess the hazards to which their workers may be exposed; evaluate the risk of exposure; and select, implement, and ensure workers use controls to prevent exposure. The table below describes dentistry work tasks associated with the exposure risk levels in OSHA's occupational exposure risk pyramid, which may serve as a guide to employers in this sector.
Dentistry work tasks associated with exposure risk levels
Note: For activities in the lower (caution) risk category, OSHA's Interim Guidance for Workers and Employers of Workers at Lower Risk of Exposure may be most appropriate.
Until more is known about how COVID-19 spreads, OSHA recommends using a combination of standard precautions, contact precautions, and droplet precautions, including eye protection (e.g., goggles or face shields), to protect dentistry workers performing patient care that does not involve aerosol-generating procedures* on individuals without suspected or confirmed COVID-19. In emergency situations when workers have exposure to suspected or confirmed COVID-19 patients, and anytime when performing aerosol-generating procedures, use standard precautions, contact precautions, airborne precautions, and eye protection (e.g., goggles or face shields) to protect dentistry workers.
*In dentistry, using dental turbines, micro-motor handpieces, ultrasonic scalers, and air-water syringes are examples of tasks that can generate aerosols. This list is not exhaustive; other procedures also may generate aerosols.
The CDC provides the most updated infection prevention and control recommendations for emergency dental procedures during the COVID-19 pandemic.
Is OSHA infection prevention guidance for dentistry the same as CDC recommendations?
- With regard to dentistry worker infection prevention, CDC guidance may appear to differ from OSHA guidance.
- OSHA's recommended infection prevention methods, including for PPE ensembles, help employers to remain in compliance with the agency's standards for Bloodborne Pathogens (29 CFR 1910.1030), Respiratory Protection (29 CFR 1910.134) and other PPE (29 CFR 1910 Subpart I).
- OSHA is addressing supply chain considerations, including respirator shortages, through enforcement flexibilities, as discussed in the Enforcement Memoranda section of the Standards page.
Employers of dentistry workers are responsible for following applicable OSHA requirements, including OSHA's Bloodborne Pathogens (29 CFR 1910.1030), Personal Protective Equipment (29 CFR 1910.132), and Respiratory Protection (29 CFR 1910.134) standards. See the Standards page for additional information on OSHA requirements related to COVID-19. OSHA's Dentistry Safety and Health Topics page provides more information on standards relevant to dentistry in general.
OSHA's Bloodborne Pathogens standard (29 CFR 1910.1030) applies to occupational exposure to human blood and other potentially infectious materials, including saliva in dental procedures. The Bloodborne Pathogens standard does not specifically apply to occupational exposure to respiratory secretions, although saliva may contain respiratory secretions (and, in dentistry, the standard applies to occupational exposure to saliva). Even when the standard does not apply, its provisions offer a framework that may help control some sources of the virus, including exposures to body fluids (e.g., respiratory secretions) not covered by the standard.
As guidance from federal, state, local, tribal, and/or territorial public health agencies and professional organizations, including the ADA, changes, consider appropriate modifications to patient procedures. Only patients needing urgent and emergency procedures should be seen during the pandemic. Consistent with CDC recommendations, all elective dental procedures should be postponed. Limiting services to urgent or emergency treatment will help control dental workers' possible exposure to sick patients.
When urgent or emergency dental care is needed, use engineering controls to shield dentistry workers, patients, and visitors from potential exposure to SARS-CoV-2. This includes easily decontaminated physical barriers or partitions between patient treatment areas (e.g., curtains separating patients in semi-private areas).
If dental offices are equipped with the capability, use local exhaust ventilation to capture and remove mists or aerosols generated during dental care.
If possible, use directional airflow, such as from fans, to ensure that air moves through staff work areas before patient treatment areas—not the reverse. A qualified industrial hygienist, ventilation engineer, or other professionals can help ensure that ventilation removes, rather than creates, workplace hazards.
Conduct telephone triage to identify whether dental issues for which patients seek care are urgent or emergent. If emergency dental care is medically necessary, complete a systematic assessment at the time of check-in to determine whether a patient should be considered a suspected or confirmed COVID-19 case.
Use teledentistry (e.g., voice or video conference) options for non-emergency dental consultations.
Consistent with the general interim guidance described above, isolate patients with suspected or confirmed COVID-19 to prevent transmission of the disease to other individuals. For example, if a patient arrives with, or begins to experience during treatment, fever, cough, or shortness of breath consistent with COVID-19, isolate the patient until the patient can be sent home or to an appropriate medical facility to seek further care.
When emergency dental care must be provided to a person with suspected or confirmed COVID-19, restrict the number of personnel entering the patient treatment area.
Minimize, or avoid without appropriate precautions, aerosol-generating procedures.
Always minimize the number of staff present when performing aerosol-generating procedures. When performing necessary aerosol-generating procedures on suspected or confirmed COVID-19 patients, it is particularly important to exclude any staff members not necessary for the procedure itself.
Safe Work Practices
When performing emergency dental care, dental care workers should follow all appropriate precautions for dentistry and healthcare workers, as well as ensuring appropriate bloodborne pathogen standards are followed when encountering saliva and blood.
Minimize using, or do not use without appropriate precautions, dental handpieces and air-water syringes. The use of ultrasonic scalers is not recommended during this time. Prioritize minimally invasive/atraumatic restorative techniques (hand instruments only).
If aerosol-generating procedures are necessary for emergency dental care, use high evacuation suction and dental dams to minimize droplet spatter and aerosols.
Perform as many tasks as possible in areas away from patients and individuals accompanying patients (e.g., do not remain in a patient care area to perform charting, sterilization, or other tasks).
Workers should avoid touching their faces, including their eyes, noses, and mouths, particularly until after they have thoroughly washed their hands after completing work and/or removing PPE.
Train and retrain workers on how to follow established protocols.
Personal Protective Equipment
Dentistry workers must use proper PPE when exposed to patients. PPE differs for the care of well patient care during the COVID-19 pandemic versus PPE needed when providing emergency care to a patient with suspected or confirmed COVID-19 (See OSHA's PPE standards at 29 CFR 1910 Subpart I).
OSHA recommends the following PPE for dentistry during the COVID-19 pandemic:
|Well patients||Patients with suspected or confirmed COVID-19|
|Dental procedures not involving aerosol-generating procedures||Dental procedures that may or are known to generate aerosols||Dental procedures not involving aerosol-generating procedures||Dental procedures that may or are known to generate aerosols|
*During extended procedures in which aerosols or other splashes/sprays of water, saliva, or other body fluids could cause moisture to collect in/on a filtering facepiece respirator, OSHA recommends using an R95, P95, or better filtering facepiece; elastomeric respirator with an appropriate cartridge; or powered air-purifying respirator (PAPR). Note that disposable N95 filtering facepiece respirators and certain cartridges for elastomeric respirators may be adversely affected by an increase in moisture and spray from certain work tasks.
Use respiratory protection as part of a comprehensive respiratory protection program that meets the requirements of OSHA's Respiratory Protection standard (29 CFR 1910.134) and includes medical exams, fit testing, and training.
When removing potentially contaminated PPE, such as an N95 respirator, do not touch the outside of the respirator without wearing gloves.
CDC has developed strategies for optimizing the supply of PPE, including specifically for:
Flexibilities Regarding OSHA’s PPE Requirements and Prioritization of PPE During COVID-19
Some healthcare facilities, including dental offices, are experiencing shortages of PPE, including gowns, face shields, face masks, and respirators, as a result of the COVID-19 pandemic. This may impact PPE availability for dentistry.
See information on PPE flexibilities and prioritization in the Personal Protective Equipment Flexibilities section within the Interim Guidance for U.S. Workers and Employers of Workers with Potential Occupational Exposures to SARS-CoV-2, above.
Cleaning and disinfection in dentistry:
Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant for appropriate contact times as indicated on the product's label) are appropriate for SARS-CoV-2 in dentistry and healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed.
When performing emergency dental procedures, if necessary, follow standard practices for disinfection and sterilization of dental devices contaminated with SARS-CoV-2, as described in the CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 and Guidelines for Infection Control in Dental Health Care Settings – 2003. In some emergency dental procedures appropriate cleaning and disinfecting techniques from bloodborne pathogen practices should be used, including protecting vacuum lines with liquid disinfectant traps and high-efficiency particulate air (HEPA) filters or filters of equivalent or superior efficiency and which are checked routinely and maintained or replaced as necessary.
Refer to List N on the EPA website for EPA-registered disinfectants that have qualified under EPA's emerging viral pathogens program for use against SARS-CoV-2.
Note that workers who perform cleaning and disinfection in healthcare may require PPE and/or other controls to protect them simultaneously from chemical hazards posed by disinfectants and from human blood, body fluids, and other potentially infectious materials to which they have occupational exposure in the healthcare environment. Employers may need to adapt guidance from this Dentistry workers and Employers section, the Environmental Services Workers and Employers section, and the interim guidance for workers and employers of workers at increased risk of occupational exposure, in order to fully protect workers performing cleaning and disinfection activities in healthcare workplaces.
Source: United States Department of Labor (Occupational Safety and Health Administration)