If you are of a certain vintage, you might recall that at one time dentistry was performed without gloves. What was known as “wet-fingered” dentistry could well leave those working in the oral health care field with pruned fingers from the constant exposure to moisture. But in light of today’s infection control awareness, barehanded dentistry is unthinkable.
In modern dental practices, attention to infection control is particularly urgent. This is especially true when you consider incidents, such as one that was widely reported in 2016, in which infection control breaches, including the failure to use appropriate personal protective equipment (PPE), in one New Jersey practice led to 15 cases of Enterococcus faecalis endocarditis — one of which was fatal.
But 21st-century PPE, as mandated by the Occupational Safety and Health Administration (OSHA), includes more than just gloves. PPE extends to face masks, eye protection and gowns. All are designed to keep oral health professionals and their patients free from cross contamination and unnecessary exposure to bacterial pathogens.
From the perspective of OSHA, the most significant PPE gain is that its use has become increasingly accepted in the dental industry. “Our inspection data from calendar years 2006–2016 estimate that citations for the Bloodborne Pathogens Standard’s PPE requirements in dentistry have remained low and steady over the past 10 years,” reports Kimberly Darby, a spokesperson for OSHA’s Office of Communications. This standard prescribes safeguards to protect oral health care professionals against the potential health hazards caused by bloodborne pathogens.
Many of today’s protocols are crystallized in the Centers for Disease Control and Prevention’s (CDC) Guidelines for Infection Control in Dental Health-Care Settings — 2003. But due in part to misinterpretations of the guidelines, they have been updated in subsequent years with summaries and checklists to enhance complete guideline comprehension. In addition, the Organization for Safety, Asepsis and Prevention (OSAP) offers educational tools on its website to help oral health professionals better understand the CDC guidelines.
One of the primary points promoted in the CDC guidelines is the value of training. The agency also recommends that practices develop written infection-control programs that are easy for every staff member to understand, as well as designate infection-control coordinators, who would receive further training and perform ongoing evaluation of programs. But PPE remains a central focus.
POINT OF SALE | DRESSING THE PART
- A number of masks are available to enhance safety in the dental office, but picking the right one for the task is paramount.
- To be effective, face masks must properly and snugly fit the face of the wearer.
- Glasses, goggles, loupes and face shields should feature side shields for increased protection.
- The well-prepared dental office will have a range of gloves on hand, including utility, examination and surgical gloves.
- Protective clothing helps to keep practitioners free of contamination from the neck down.
- Correct fit is critical in order for personal protective equipment to be effective.
Many think of gloves as a first line of defense in protecting dental practitioners from cross contamination that can occur through contact with blood, saliva and mucous membranes. However, the use of rotary and other motorized instruments can send spray, containing infectious particulates, airborne to land on unprotected surfaces, including hands. The use of gloves also protects patients from exposure to any pathogens that may still be present on clinicians’ hands.1
Single-use and disposable examination gloves worn in dental practice are available for various applications, in a range of materials. Nonmedical, or utility, gloves are worn for tasks not directly related to patient care. These include washing and disinfection of instruments, housekeeping, and handling sharps or chemicals. Utility gloves may be sanitized and reused.1
Disposable examination gloves are used for patient care in the course of nonsurgical treatments. Regulated as a medical device by the United States Food and Drug Administration (FDA), these gloves may be sterile or nonsterile and must be discarded after use on a patient.1 Clinicians will appreciate many ergonomic benefits, including multiple sizes, textures, and thicknesses for user comfort and control.
Surgical gloves are the only type of glove permitted for surgical procedures. Also recognized by the FDA as medical devices, they are sterile, single-use items. Surgical gloves are designed three-dimensionally, instead of on flat molds, and come in a wider range of sizes. In general, they provide a more ergonomic fit than the standard exam glove.1
Long made of natural-rubber latex (NRL), gloves used in medical and dental practices have become widely available in other materials due to the emergence of allergies in both practitioners and patients in response to the proteins present in latex. These sensitivities seem to develop over time through continued use of NRL.
“A big advance has been the move away from latex gloves, which may cause hypersensitivity or allergy among some patients and providers,” says Eve Cuny, MS, director of Environmental Health and Safety and an associate professor in the Department of Diagnostic Services at the University of the Pacific Arthur A. Dugoni School of Dentistry in San Francisco
Lady Macbeth’s obsessive handwashing would have been spot on had she worked in the oral health care field. Despite the barrier protection afforded by personal protective equipment such as gloves, the Centers for Disease Control and Prevention emphasizes the importance of handwashing — and drying — in its Guidelines for Infection Control in Dental Health-Care Settings — 2003. In fact, the agency considers hand hygiene “the single most critical measure for reducing the risk of transmitting organisms to patients and health care providers.”1
But while using an alcohol rub if the hands aren’t visibly soiled, or washing with antibacterial or even plain soap and water is sufficient for nonsurgical cases, when it comes to surgical procedures, hand antisepsis is vital. Therefore, plain soap won’t cut it, and using an antibacterial soap or alcohol rub is a must prior to performing surgery. This is because, in the event of a puncture or tear of the glove, hands that are washed with antimicrobial soap or an alcohol rub are less likely to introduce bacteria into operative wounds.1
Agents used for hand antisepsis should be broad spectrum, persistent, nonirritating and fast acting. Commercially available handwashes designed for health care providers may be the best option. Alcohol rubs should include antiseptic formulations such as chlorhexidine, quaternary ammonium compounds, octenidine or triclosan. And while lotions are discouraged in conjunction with glove wear, as some of the ingredients (particularly petroleum) can interact (chiefly with latex) to break down the material, they are beneficial for overall hand health once gloves come off at the end of the day.1
Alternatives to NRL include nitrile, polyvinyl chloride, polyurethane and a range of blends. Still, latex is valued for its superior tactility, elasticity, strength and comfort as a barrier protector. As a result, new low-protein NRL gloves have begun to surface.
Another issue with latex is latex powder, which is traditionally added to NRL gloves to ease donning and doffing. But latex proteins have a tendency to attach to the powder, so the practice has been curtailed — especially because the powder becomes aerosolized during donning or doffing of gloves, exacerbating a number of problems such as allergies and asthma — and increasing the chance of cross contamination.
Cuny, who also sits on the OSAP board explains, “In 2016, the FDA banned the use of powders in gloves, citing that complications could include ‘severe airway inflammation and hypersensitivity reactions. Powder particles may also trigger the body’s immune response, causing tissue to form around the particles (granulomas) or scar tissue formation (adhesions) which can lead to surgical complications.’”
Because it isn’t uncommon for spray and spatter to go airborne during treatment, where they may linger long enough to be inhaled, surgical masks and face shields are vitally important pieces of PPE. To be sold as such in the U.S., surgical masks must be cleared by the FDA as capable of resisting spatter from blood and body fluids. They are said to be more than 95% effective in filtering bacteria emanating from the wearer, while also protecting the clinician from any large droplets or particles of potentially infectious material from the patient.1 As an added bonus, they prevent wearers from unconsciously touching their contaminated fingers to their noses or mouths.1
Most masks are designed to cover the nose and mouth, protecting mucous membranes from contamination resulting from spatter. But choosing the right mask for the job is the best strategy. What are known as dust or utility masks may be used simply as barriers for short procedures, in which no fluid, spray or aerosols will be produced, but they do not meet the performance standards established by the American Society for Testing Materials (ASTM) for barrier protection from such procedural byproducts. For that, clinicians have three choices that depend on how much fluid, spray and aerosols are anticipated.
ASTM level 1 masks offer bacterial filtration efficiency (BFE) and particulate filtration efficiency (PFE) equal to or more than 95%, but score low in fluid resistance. ASTM level 2 masks provide BFE and PFE equal to or more than 98%, as well as offer moderate fluid resistance. ASTM level 3 masks offer the same BFE and PFE as level 2, but score high in fluid resistance.
But for maximum filtration, which affords more thorough respiratory protection when airborne infection is a possibility, clinicians need to step up to the National Institute for Occupational Safety and Health-approved N95 respirator. This type of respirator, capable of filtering more than 95% of airborne particles as small as 1-μm, resembles a surgical mask, and is the one most likely to be used in the medical-dental environment. Respirators may become increasingly important in light of emergent viruses and in the event practitioners are treating patients infected with airborne viruses, such as tuberculosis and H1N1 influenza.1
Cross contamination: Transferring a contaminant from one surface to another.
Enterococcus faecalis: A species of bacteria found in feces.
Granuloma: A collection of immune cells that attempts to wall off a foreign substance in the body.
Pathogen: An agent that causes disease.
μ: Micrometer; one millionth of a meter.
Available in a variety of styles and sizes, some N95 respirators feature exhalation valves to ease breathing, reduce moisture buildup, and keep the face cool (though these can’t be used if a sterile field is required). N95 respirator masks must be individually fit-tested to ensure proper fit, which includes the forming of a tight seal against the face. This results in inhaled air being pulled through the mask’s filter, without leaking around the edges. At the same time, wearers are generally trained in how to properly place the mask, per OSHA requirements.1,2
One caveat where masks are concerned has to do with gray-market goods. While those with whom we spoke are not aware of an overarching problem with imported PPE for the dental industry, according to Darby, “There have been issues during outbreaks of influenza, HINI, Ebola, etc. in health-care settings where respirators and surgical masks were imported, and may not have met all OSHA standards.”
But, says Cuny, “I believe this is most likely an issue outside of the U.S., where limited financial resources and lack of access to appropriate supplies are a larger issue than they are for most settings in North America.”
Nonetheless, there is general agreement that the best way for end users to avoid gray market issues is to purchase their PPE from trusted suppliers, such as dental sales reps.
Masks should be comfortable, breathable and splash resistant. Features such as headstraps and nosepieces must fit snugly, and some masks are designed with a flange to improve the seal around the wearer’s face. Most masks are disposable. But some manufacturers are now offering reusable masks that can be decontaminated between uses.
Adhering to standards established by the American National Standards Institute, protective eyewear is meant to provide barrier protection for eyes, guarding against airborne debris and spatter from blood and saliva. Eyewear is becoming standard not only for oral health professionals, but also for patients to wear during treatment to protect against flying debris and spatter.
Types of eyewear include glasses with impact-resistant lenses and side shields or wraparound designs; goggles, which provide a seal against the face; and face shields, which provide full facial coverage. Even loupes should feature side shields to keep eyes safe from contamination, though when treatments are expected to generate high levels of spray or spatter, face shields may be the safest bet.1
Glasses and goggles come in many designs, but certain features are important for protection from contamination. These include a tight seal between the lenses and their frames to guard against airborne microorganisms or spatter; scratch-resistant, antifog lenses for optical clarity; and comfortable styling via adjustable headbands. According to OSAP, eyewear should be washed and disinfected between patients.
When it comes to full body protection, gowns or lab coats should be worn over street clothes or uniforms to keep contamination at bay. Per OSHA, sleeves should be long enough to protect the wearer’s forearms from exposure to bloodborne or other pathogens. There is agreement between the CDC and OSHA that there is no need to change gowns and lab coats between patients as long as there is no visible soiling.1,3,4
In adherence with OSHA standards, protective clothing must be laundered by the employer, rather than taken home. Some dental offices opt for using a professional medical/dental laundering service to clean gowns, lab coats and other contaminated textiles.4
HOW TO HELP
The choices available in PPE can be overwhelming to busy practitioners. When asked how sales reps can best assist their clients in negotiating the purchase of PPE, Cuny advises, “Help customers understand what the various standards are for the PPE and how to use those standards to make clinical selections. For example, they should understand the classifications of surgical masks and how to use those classifications to select the appropriate product for the types of procedures they typically perform.”
Darby adds, “Sales reps would benefit from becoming familiar with the OSHA Bloodborne Pathogens Standards and other literature available on OSHA’s website.”5–7
Dressing to successfully thwart the spread of infection is not only smart, but it makes a fashion statement — that clinicians care about themselves, their staff and their patients.
- Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM. Guidelines for infection control in dental health-care settings — 2003. Centers for Disease Control and Prevention. Available at: cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm. Accessed December 1, 2017.
- Occupational Safety and Health Administration. OSHA fact sheet: Respiratory infection control: Respirators versus surgical masks. United States Department of Labor. Available at: osha.gov/Publications/respirators-vs-surgicalmasks-factsheet.html. Accessed December 1, 2017.
- Occupational Safety and Health Administration. OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030(d). United States Department of Labor. Available at: osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10051. Accessed December 1, 2017.
- Cuny E. Gear up for infection battles. Mentor. 2017;8(4):30–36.
- Occupational Safety and Health Administration. Dentistry. United States Department of Labor. Available at: osha.gov/SLTC/dentistry/index.html. Accessed December 1, 2017.
- Occupational Safety and Health Administration. Health care. United States Department of Labor. Available at: osha.gov/SLTC/healthcarefacilities/index.html. Accessed December 1, 2017.
- Occupational Safety and Health Administration. Personal Protective Equipment. United States Department of Labor. Available at:
sha.gov/SLTC/personalprotectiveequipment/. Accessed December 1, 2017.
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From MENTOR. January 2018;9(1): 35-38.