Personal protective equipment (PPE) offers a way of reducing the infection when treating patients, by minimizing exposure to contaminated body fluids. During epidemics/pandemics of highly infectious diseases, such as COVID-19, health care workers (HCW) are at greater risk of infection than the general population.
The recently published Cochrane Review (Verbeek et al, 2020), aimed to evaluate which type of full-body PPE and which method of donning (putting on) or doffing (removing) PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols. For COVID-19, this entails preventing droplets from entering mouth, nose or eyes and preventing them from contaminating the skin elsewhere.
Dentists and members of the dental team work in close proximity, usually face-to-face, with patients often for sustained periods of time. As part of routine care, they are exposed to saliva and blood and carry out aerosol-generating procedures (e.g. use of high-speed air rotors and ultrasonic scalers), making the findings of this review highly relevant to them.
PPE is part of Standard Precaution for infection and control. In tandem with other measures such as good ventilations, correct handling of waste, immunizations and correct working practices, PPE can help minimize the possibility of exposure to infections.
The term PPE is used to describe all protective equipment a dentist or dental nurse may use in the surgery. Typically, this might include the following elements :
- PPE for Eyes – goggles, visors. Normal glasses do not provide sufficient eye protection so goggles or visors should be worn during treatments and when manually cleaning instruments. Patients should be given eye protection prior to any examination or treatment.
- PPE for Hands – sterile, single use gloves. These should be put on at the start of treatment and removed at the end. They need to be removed aseptically so that the outside of the glove isn’t touched by bare skin. Sterile gloves are needed for invasive surgery while heavy duty gloves are required for cleaning of dental instruments.
- PPE for the face – masks and respirators. Conventional single use masks provide barriers against splatter but do not generally protect the wearer effectively against aerosol inhalation. Respirator masks filter inhaled air and remove microbes.
- PPE for the body – aprons, gowns. Aprons or gowns are often wore over the top of dental uniforms to act as barrier to fluids.
There are several aspects to be aware of concerning the use of PPE. The order of putting on and removing PPE is vital in order to prevent the spread of infection. These following sequences were advised :
- For putting on PPE the order is uniform-apron-mask-eye protection then gloves.
- For removing PPE the order is gloves-apron-eye protection-mask-uniform.
Throughout the process, it is important to keep hands away from the face and limit any surfaces touched in the patient environment. Gloves should be change if they become torn or highly contaminated, and always between patients. Hands should be cleaned after disposing of gloves.
Single use items should be disposed as hazardous clinical waste and managed according to practice waste management policy.
The masks and gloves protect the dental team from any contact with blood, saliva, mucous and other bodily fluids. These fluids can contain viruses and bacteria that can spread infection; many illnesses can only be spread by direct contact between bodily fluids.
PPE protects patients too. The gloves your dentist and team use are sterile, which limits the chances that you’ll contract an illness from them. This is especially important for immune compromised individuals. Sterile gloves are used for each patient and are always discarded after use.
Your dentist will always wear PPE whether or not you display symptoms of an illness. Infection control requires that every patient is infected. You must let your dentist know if you have an illness before your visit so you and they can plan appropriately.
The amount of PPE your dentist will wear can vary significantly depending on your health conditions. People with highly infectious or dangerous diseases would be treated by medical professionals wearing significantly more PPE than with patients who seem healthy.
Standard PPE equipment doesn’t protect your dentist from every type of infection. You’ve probably heard that most masks don’t protect adequately from airborne infections – they only act as barriers for fluids. That’s why there’s a growing need in the current environment for specialized PPE like N95 masks.
The chain of infection
In addition to following safety protocols, it is worthwhile to remember the difference between bacteria and viruses when thinking about the chain of infection. Although both are microbes with the potential to cause infections, they behave in very different ways. Viruses, such as the novel coronavirus, are smaller than even the smallest of bacteria, reproduce quickly by using host cells to make new viruses, and are much more likely to cause disease. In general, viral infections are also more challenging to treat due to their tiny size and as they reproduce inside of cells.
The chain of infection refers to the series of events that allow pathogens to cause infection in a person. This chain begins with an infectious agent, or pathogen, finding a “portal of exit.” Upon finding this exit, the pathogen can leave its reservoir and travel through space. As it travels, whether by direct or indirect contact, it searches for a “portal of entry” and enters a new, susceptible host.
This may sound complicated, but it can happen within an instant. The easiest way to stop pathogens from spreading is to interrupt the chain through understanding the portals of exit and entry and modes of viral transmission and adopt the appropriate infection control measures.
Some ways to break the cycle of infection include eliminating the agent at its source of transmission, protecting portals of entry, and increasing the host’s defense so that there are fewer new and susceptible hosts. We examine how dental professionals can increase their defenses against infection in the workplace.
The fight against infection begins with the implementation of the hierarchy of controls as follows :
- Eliminate workplace conditions or contagious individuals that negatively impact well-being.
- Replace or substitute unsafe/unhealthy working practices with policies that improve the culture of safety and health in the workplace
- Redesign or rearrange the workplace to promote safer practices.
- Provide safety and health resources for employees.
- Encourage personal change, so that individuals will do their part to keep the office safe.
Following these control guidelines is the first step to bolstering your practice’s defenses against the spread of viral infections. The second step is to recognize and understand the unique dangers present in a dental office. The face-to-face nature of dentistry, in combination with the exposure to saliva, blood, and other bodily fluids, makes it very easy to transmit infections. As a result, dental professionals must adopt infection control measures to limit the airborne spread (often through aerosols), the contact spread, and the contamination of surfaces. Some protocols to protect against these transmissions of infection include the following.
Screening patients prior to their appointments
The best way to break the chain of infection is to prevent the introduction of the pathogens in the first place. Sick patients and employees should not enter the building. Screening patients, by asking basic triage questions before their appointments is the best way to determine if they are healthy enough to continue with their scheduled procedures. This does not mean only during a pandemic but forever!
Staying home if you are sick
Any employee that does not feel well should stay home. If you are ill, you are a potential hazard in the workplace and better serve everyone by isolating yourself and getting better.
Practicing good hand hygiene
Oral professionals should properly wash or disinfect their hands before the patient examination, before starting any procedures, after touching the patient, and after touching any of the surrounding medical equipment.
Opting for procedures that create fewer aerosols, if possible
The aerosols and spatter created in many dental procedures can stay airborne for long periods, thereby creating a risk for the transmission of infection via the respiratory passages. Certain procedures, such as those that use ultrasonic scalers, air polishing, air abrasion, and air-water syringes, create more aerosols than others. During a pandemic or outbreak, it is wise to opt for methods that will create fewer airborne droplets.
Implementing preoperational mouth rinses before dental procedures
Preoperational antimicrobial mouth rinse may reduce the number of oral microbes present in the patient’s mouth. In procedures known to create more aerosols, a mouth rinse can limit exposure to pathogens.
Utilizing rubber dams
A rubber dam is a thin, six-inch, square sheet of latex used to isolate one or more teeth from the rest of the mouth during dental procedures. This isolation can reduce the likelihood of spreading bacteria and saliva from the patient’s mouth.
Disinfecting with strict safety measures
Regular cleaning of your office is always important and should follow the directions present on the cleaning and disinfectant supplies. When applicable, implement extra measures such as air cleaning systems to reduce the size of any bio aerosols that might be present in the air.
Reviewing the proper use of PPE
As stated earlier, PPE is the final defense, but it only works if used properly. Worn whenever there is potential for contact with spray or spatter, there must also be strict adherence to the guidelines for putting on, taking off, and disposing of the materials.
Preventative care is the best approach
Many may tell you that their protocols are good enough because no one has gotten sick. However, that attitude is not good enough. We cannot wait for someone to get sick before we decide to follow precautionary principles. Yes, it will require effort on our parts, but if COVID-19 has taught us anything, it is that that effort is vital for the continued health of our communities.
Even after all of this is over and we go back to “business as usual,” dental professionals need to re-evaluate their protocols and make sure that we are doing everything possible to protect workers and patients. Dental offices have characteristics that warrant additional infection control protocols and we must be aware of how our practices have the potential to aerosolize infectious aerosols and be a vector for disease.
Although COVID-19 may seem like a complete aberration, there have been other viruses throughout history that have changed the way we live. Nevertheless, we have survived and learned how to protect ourselves better.