The end of each year gives us a good opportunity to reflect on the past and improve on procedures and protocols in the year ahead.
As the year winds to a close, it is a good time to reflect back on what we learned. It is a good time to ponder lessons, learned and carry those with us into the new year. Not surprisingly, COVID is still importing its lessons. But, in addition to the Big Bad, there are other things that we should’ve gleaned from 2022.
While many people may be tired of hearing about COVID-19, that doesn’t make it any less of a threat. And one of the indicators of its prevalence and danger is its community levels. It is important to know the percentage of the population that is infected and who is at risk of infection says Jackie Dorst, RDH, BS, an infection prevention consultant and speaker.
“The number of infections contributes to the disease transmission,” Dorst says. “And in 2022, we learned from these new, emerging variants that the tests were not effective. The tests were not detecting all of the variants that were coming up. One of the variants was even named the Stealth Variant, because it was evading the detection of the tests.”
Wastewater testing is a new, innovative way of testing for SARS-CoV-2, Dorst says. The virus can be detected from a person’s material waste, and a wastewater treatment facility can take daily samples that can detect the COVID-19 virus or the SARS-CoV-2 virus and determine which variant it is, she explains.
“And when the levels start to go up, that’s an immediate indication that there’s a high risk of transmission in that community. With that information, then the public health department should issue some alerts that you may want to step up precautions. Knowing what the level of transmission is in our communities is vitally important for public health,” Dorst says.
Staff precautions against infection are well-established, but the pandemic has reminded everyone just how important those precautions are. Although dental professionals may not have been aware that it is called transmission-based precautions, the Centers for Disease Control and Prevention (CDC), has had contact-, droplet-, and air-borne-based precautions in place for some time, according to infection prevention speaker and consultant Karen Daw, ‘The OSHA Lady’.
“And part of it was knowing, for example, that if we’re going to have contact with blood or body fluid or contaminated items, that we’re going to protect our skin and we’re going to disinfect items. Then there were droplet precautions that said, ‘OK, we might anticipate exposure to our eyes, nose, and mouth. We’re going to protect our mucus membranes.’ And then COVID-19 introduced us to airborne precautions. So, all of this foundational-level information in safety has served us well up to this point.”
The attention on droplets underscored dentistry’s role as a healthcare provider—something that dentistry has always known, but patients might not have recognized.
“What we’re seeing is that the dental industry is finally being treated like the medical industry, and we’ve been doing it right all along,” Daw says. “That makes sense, because we’ve seen the Occupational Safety and Health Administration (OSHA) and the CDC migrate towards one another and say, ‘OK, we shouldn’t be treating dentistry any different than any other healthcare profession.’”
“I have been emphasizing to dental practices to get used to calling yourselves dental healthcare providers” she continues. “I used to hear about my dental accounts saying patients were coming in and screaming at them, wondering why they have to wear a mask in the dental office. Do you think they’re giving pushback at their physician’s office or the hospital about mask mandates? No, but they’ll do it in the dental office. Why? Because there’s a huge disconnect about dentistry and being under the healthcare umbrella. Certainly, OSHA and the CDC see it that way.”
Infection control in healthcare settings is dynamic in that it constantly changes with the times. For example, dentistry in the early 1990s began mandating personal protective equipment (PPE) such as gloves in response to the AIDS epidemic. Since the COVID-19 pandemic, healthcare settings have become more attentive to respiratory protections.
Through the research and education that has been done on respiratory protection, dental professionals should fully understand that a procedure mask has gaps around the edge, Dorst explains. These masks allow breath to escape when we exhale, but it also allows germs to enter around the loose edges of the mask, she says.
“The N95 mask gives us true airborne disease protection,” Dorst says. “We need to be wearing a close-fitting, fit-tested N95 respirator, with a close fit to give us that seal so that all of the air that we are exhaling goes through the filter membrane of the N95 respirator.
“The precautions that we’ve learned during this pandemic are going to apply to all of the other airborne diseases that our patients can come in with,” she continues. “There are other airborne diseases in addition to SaARS-CoV-2. The first airborne disease that most people think of is tuberculosis, fortunately it is very low infectivity and is difficult to acquire an infection. But what about influenza and respiratory syncytial virus (RSV)?”
In 2016, contaminated dental unit water lines in 2 pediatric dental practices caused serious health problems for dozens of children. Those incidents served as a wake-up call for dental practices to monitor, clean, and maintain their dental unit waterlines. Regrettably a similar infection occurred in 2022.
As a result of these cases, hundreds of children were impacted, causes deafness and a 7-year-old girl had part of her jaw removed, Daw says. These instances should serve as a warning to other practices to regularly test their waterlines.
“Test your waterlines, people,” she says. “Use a product to monitor your waterlines to make sure we’re preventing biofilm. We’ve had 6 years to get it right, and it happened again. The CDC is actively investigating, and they issued a health advisory specifically about dental waterlines that went national [on November 4, 2022]. That had everybody thinking, ‘Oh my gosh, are we doing the right thing with our dental unit waterlines?’ It took something really negative to make us go to think, ‘OK, we know we’re supposed to be doing this, now we’ve got to do it. And we’ve got to do it ASAP.’ There’s just no excuse for us not to test our waterlines, treat our waterlines, and continuously monitor to make sure it’s safe,” Daw says.
Fortunately, infections weren’t more widespread, but they easily could have been, especially for practices that aren’t as vigilant that they should be.
“I think it’s not just that 1 practice,” Daw observes. “I think a lot of practices will ask, ‘Well, is it mandatory or is it just recommended?’ And that’s why, when a practice or a hospital hires me, I tell them, ‘You’re going to hear me talk about the CDC recommendations as if they’re the law of the land, because you can certainly be and sometimes your local dental board has adopted it as part of the administrative code for your state. OSHA can also enforce that under the General Duty Clause. And if there is an infection control breach, any attorney worth their salt is going to ask, ‘Is there a nationally accepted standard of care for safety and are you following it?’”
When the pandemic started, there was a shortage of PPE. As a result, regulatory agencies eased their standards with Emergency Use Authorization (EUA) for alternate US Food and Drug Administration (FDA)- and Environmental Protection Agency (EPA)-approved products. However, in 2021 supply levels returned to normal, and those standards were restored, so there was no excuse to have used substandard PPE in 2022.
In June of 2021, the FDA removed its EUA for KN95 respirators, Dorst explains, and practices have returned to using N95 respirators. To confirm that your practice is using verified N95 respirators, visit the National Institute for Occupational Safety and Health (NIOSH) website.
In May 2020, the FDA banned the use of some imported KN95 masks that did not meet certain medical standards for protection. The lesson here is that practices should be sure to verify the equipment and infection control products that they are using.
“Verify the products that you use for infection control, that they are legitimate, approved products that meet the standards of the regulatory agencies like the FDA, NIOSH, and the EPA,” Dorst says.
Daw worries that practices are becoming complacent as the pandemic seems to ease.
“OSHA is working on an a COVID-19 standard right now, also an infectious disease standard, and a workplace violence standard,” she observes. “As far as the past year goes, I’m at this point where if we haven’t been doing it all along, I’m a little bit worried about your practice, because of the stuff that was introduced to us early in the pandemic. And maybe we were overdoing it in some cases, but now we’ve kind of leveled off. But there are some things that are just not going to go away. We’ve gone all the way back to doing things the way they used to be. I’m concerned because we’re letting our guard down in that respect.”
Looking forward, she expects some of those requirements to be codified by regulatory agencies.
‘There are some things that we introduced early on the pandemic that I think are going to be included in the upcoming standard,” Daw says. “I really think, looking at the science, looking at best practices, it is still going to be super important. For this past year, I saw one of two scenarios: I saw practices that have been following along with the guidance and doing what they’re supposed to be doing per the CDC and per OSHA. And then I saw practices that just did a complete 180. They were like, ‘Okay, well they dropped the mask mandates in public. We can go to the grocery store and go to Costco without masks on, so our practice is going to go back to doing things the way we used to.’ And that really worries me, because we’re not going to go back to doing everything a hundred percent the way we used to. Same thing with HIV/AIDS. As a result of that, we saw a new set of guidance that became the standard, became the norm. And I think we’re going to see that with COVID, moving forward.”
The end of each year gives us a good opportunity to reflect on the past and improve on procedures and protocols in the year ahead. Hopefully, we can learn lessons from 2022 that will make 2023 healthier and safer.