The Risky Business of Clinical Dental Hygiene: What to do if you test positive for COVID

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I am repeatedly made aware of the threat of viral contamination whenever I read articles that delineate the occupations that are at greatest risk from COVID-19 transmission. In reading the most disturbing articles on this topic, I find that the dental hygiene profession always comes in at the number 1 spot. Medical professionals are rated in the top nine along with flight attendants, hairdressers, restaurant and hospitality workers, firefighters, kindergarten teachers, and school bus drivers, according to the U.S. Department of Labor’s Occupational Information Network (O*Net) database.¹ If this was the only article where hygienists were listed at the top, I’d be skeptical, but we are often ranked first on these lists.

As you know, I participate in several dental hygiene groups on Facebook and enjoy exchanging the latest news with my hygiene colleagues. Over the last few months, the COVID-19 pandemic has dominated blog entries on a wide variety of media platforms about hygienists’ testing positive for COVID-19. What’s missing from the discussions are detailed instructions on what to do next if you have COVID-19 symptoms while actively practicing dental hygiene. The majority of hygienists testing positive are employed in a private practice setting.

In June, I received an anonymous post from a hygienist who was concerned for another hygienist named Frances. I just happened to read the post and told the hygienist I would help Frances to the best of my ability. Frances suspected that she had become infected while working as a hygiene temp. Transmission did not take place during the provision of clinical care but from one COVID-19 infected employee to two other employees. Here’s her story and most of the story is written in Frances’s words:

In June 2020, I was employed by a DSO for a period of three weeks. I reported to work on a Monday morning after being trained at another location. After lunch, the DSO dentist informed me that the hygienist who trained me at the first location tested positive for COVID-19 and was hospitalized. He suggested that I keep the information to myself until he could confirm what he was told. I had worked with this particular hygienist on the Thursday before working at this new location. Moments later, the dentist approached me, accompanied by the office manager. Together, they told me I needed to leave the office to get tested for COVID-19. The dentist told the office manager that he would leave if management didn’t allow me to leave immediately and he also implied that I could not work without him being present in the office.

I was assured that I would be paid for the rest of the day and I was told not to tell anyone about the situation at hand. I felt so nervous that I forgot to clock out and rushed around the surrounding area, in my car, looking for a place to be tested. I could not find any testing facility that would accommodate me for testing that same day. In the meantime, I telephoned my daughter who lives with me (along with her two young children) and I remembered her mentioning that her food tasted odd while eating a meal on Sunday. On Tuesday, the four of us found a medical immediate care facility near our home that was willing to test us, and we waited in line for six hours. The test cost us $175 each and both my daughter and I tested positive for COVID-19.

I immediately texted test results to my office manager who asked me to email results to the district manager of the DSO. Later that afternoon, I received a call from a DSO Human Resources representative, who was rude and condescending. Her tone was accusatory, [which took me aback], and she seemed to question my credibility. I was also told that, as a new hire, I wasn’t eligible for healthcare insurance until September and that I could not file for workman’s compensation because there was no proof that my COVID-19 infection came from the DSO employee. I told her I felt strongly that I became infected by the other hygienist. During training, the hygienist was unmasked in the break room and we were in close proximity to each other. The HR representative seemed surprised that I knew as much as I did about the other hygienist’s COVID-19 status and she seemed more concerned about my getting compensated for the day and less concerned about my welfare. She also mentioned that it was not their place (dentist and office manager) to tell me to leave work and get tested. The representative wanted to know if I had told anyone else and she ended the conversation by saying she could do nothing else for me but that she would pray for my recovery. She reiterated that I should [keep it to myself] and that I should give all exposure details to the DSO District Manager.

In talking to my office manager, she indicated that she had been in communication with HR and that I had been “taken care of.” To be honest, I felt like an inconvenience or inanimate object that management just wanted to push aside, and I also felt as though the entire situation had been swept under a rug.

Eventually, I talked to the other hygienist who was hospitalized with COVID-19 and she indicated that the DSO knew on Friday (the day after my training) that she had tested positive for COVID-19. In her opinion, I should have been informed and the DSO should have paid for my testing cost. Moreover, I was sent to two different locations where I could have infected patients and staff. I also found out that the dental assistant who was in the break room with the infectious dental hygienist tested positive for COVID-19, as well.

Ever since I tested positive, I have not heard [from] the District Manager. I would have told her that it was a strong possibility that the dental assistant and I contracted COVID-19 from the infected hygienist while in the break room where she was unmasked and chatty.

I guess what bothers me the most about my employment was the realization that upholding ethical standards and “doing no harm” (an oath that was repeated over and over in my dental hygiene educational program) seems to be a thing of the past. I will no longer work for this company. Its ethical violations put staff and patients at risk and my views were totally dismissed. There was no open discussion of my ethical and clinical concerns.

Frances

What protective steps should the practice have followed to mitigate risk to Frances and other staff?

These are trying and unusual times for dental practices, and as all employers confront the COVID-19 pandemic, special attention must be paid to balancing a safe work environment for employees and patients with a concerted effort to avoid potential liability by taking certain protective actions.² Tailored guidance is necessary to protect the dental hygienist and this includes careful and continuous reference to governmental regulations and reporting obligations. Staying current from various authorities is essential as issues related to the COVID-19 pandemic are constantly evolving. The American Dental Association (ADA), the Centers for Disease Control and Prevention (CDC), the Occupational Safety and Health Administration (OSHA), and the U.S. Food and Drug Administration, among others, offer guidance and typically report developments that are revised as new issues emerge.

Employees with acute respiratory illness symptoms (such as fever, coughing, and shortness of breath) should be separated from other workers immediately and sent home. Hygienists who test positive should report the incident to OSHA and to local and state health departments as soon as possible.² If the employer learns that a dental hygienist has tested positive for COVID-19, the employer is obligated to notify other staff who interacted with that hygienist while protecting the confidentiality of the hygienist who is ill.² If hygienists fear for their health/safety, they are probably protected by OSHA’s anti-retaliation provision and should not receive any disciplinary action.³

Create an aerosol transmission plan and add it to the dental practice’s existing infection control plan to address COVID-19 pandemic engineering controls, PPE recommendations, and staff/patient safety issues that apply and continue to evolve during the COVID-19 pandemic. Follow all the guidelines issued by the above-mentioned agencies in applying standard, contact, and droplet precautions.³ In addition, guidelines for group and social distancing among staff should be added and all team members should be encouraged to take breaks and eat lunch—either outside or in their cars—to avoid removing appropriate level 3 or N95 masks in the office.

If a dental hygienist becomes infected with COVID-19 at work, it’s possible that the illness may be covered under workman’s compensation and they may even have rights to protected time off under the Family and Medical Leave Act (FMLA) and state family and medical leave laws.³

The ADA provides guidance for staff members who test positive for COVID-19, however, the guidance doesn’t fully address some of a hygienist’s concerns as a healthcare provider. Written guidance that pertains to the practice of dental hygiene is available if you can sift through the myriad of documents online but it’s not easy to organize and apply. In Canada, the Canadian Dental Hygienist Association (CDHA) has issued its own written guidance for dental hygiene practice during the COVID-19 pandemic.

Times are indeed changing, and dentistry needs to adapt to the new normal. It’s painful for all of us but somehow, we need to plow through the weeds and plant a new field. Dental hygiene is uniquely positioned to be a very high-risk profession during the COVID-19 pandemic and hygienists must be given every consideration in planning a daily schedule that will not result in unnecessary fear for their own health and safety. Hygienists want to care for patients to the best of their ability, but we must not forget that morale is low, and many hygienists are looking for alternatives to private dental practice.

In summary, anytime an RDH tests positive for COVID-19, the local health department should be able to provide guidance and the next steps. Local health department guidance is based on the CDC’s Interim Guidance for Businesses and Employers Responding to COVID-19.⁵ Be ready to work with the health department to gather information about the reported exposure right away. It is probably a good idea to modify your office dental infection control plan to include sections on how to prevent and manage COVID-19 staff exposure. What remains to be seen is whether U.S. congressional legislation protecting employers from liability for workplace infections will be passed or considered in Congress.

Contract tracing for healthcare professionals has gone unnoticed and there’s no sign of contract tracing being done in dentistry. The one federal agency responsible for protecting workers including dental—OSHA)—is not monitoring working conditions.⁶ Even deaths of healthcare workers have gone largely unreported to OSHA and the state worker safety programs OSHA oversees. In addition, legislative efforts by Congress are attempting to limit or remove employer liability for workplace infections.⁶

References:

1. Biasco, Paul. “As Americans Go Back to Work, These Are the 9 Riskiest Jobs to Have in the Middle of the Pandemic.” Business Insider. Business Insider, July 13, 2020. https://www.businessinsider.com/riskiest-jobs-after-coronavirus-lockdowns-lift-2020-6.
2. Keville, Jordan, Betsy Carroll, John Hodges-Howell, and Rebecca L. Williams. “On the Coronavirus Front Line: Legal Issues for Healthcare Providers: Davis Wright Tremaine.” Employment Advisor | Davis Wright Tremaine, March 13, 2020. https://www.dwt.com/blogs/employment-labor-and-benefits/2020/03/healthcare-employer-coronavirus-legal-issues.
3. “Recommended Practices for Anti-Retaliation Programs.” osha.gov. Occupational Safety and Health Administration. Accessed July 2020. https://www.osha.gov/Publications/OSHA3905.pdf.
4. “What to Do If Someone on Your Staff Tests Positive for COVID-19.” ada.org. American Dental Association, June 24, 2020. http://www.ada.org/~/media/CPS/Files/COVID/A_Positive_COVID-19_Test_Result_On_Your_Staff.pdf.
5. “COVID-19 Guidance: Businesses and Employers.” cdc.gov. Centers for Disease Control and Prevention, May 6, 2020. https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html.
6. Ellis, Blake, and Melanie Hicken. “Nursing Home Worker Deaths Going Unscrutinized.” cnn.com. CNN, July 23, 2020. https://www.cnn.com/2020/07/23/us/nursing-home-worker-death-investigations-osha-invs/index.html.