Greater use of personal protective equipment (PPE) by dental personnel began in the mid-1980s. Increased demand caused spot shortages, especially of examination gloves. New and improved types of PPE were soon developed. Much of this heightened interest was due to the emergence of HIV/AIDS within the United States.1-5
Workers in many different occupations are at risk of exposure to bloodborne pathogens such as hepatitis B, hepatitis C, and HIV/AIDS. Dental healthcare personnel (DHCP) are at risk for exposure. In 1991 OSHA issued the Bloodborne Pathogens Standard to protect workers from this risk.4 In 2001 in response to the Needlestick Safety and Prevention Act, OSHA revised the Bloodborne Pathogens Standard.5 The revised standard clarifies the need for employers to select safer needle devices and to involve employees in identifying and choosing these devices.
The OSHA Bloodborne Pathogens Standard defines PPE as specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (eg, uniforms, pants, shirts, or blouses) not intended to function as protection against a hazard are not considered to be PPE.5
The Standard states that when there is a chance of occupational exposure the employer shall provide, at no cost to the employee, appropriate personal protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal protective equipment will be considered “appropriate” only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time that the protective equipment will be used.5
A hierarchy of safety and health controls exists. Engineering controls are the most effective control for dental environments. Engineering controls are control methods (eg, sharps disposal containers, self-sheathing needles, safer medical devices such as sharps with engineered sharps injury protections, and needleless systems) that isolate or remove an occupational hazard from the workplace.1-7
The next most effective control is work practice controls, which can be defined as controls that reduce the likelihood of exposure by altering the manner in which a task is performed (eg, prohibiting recapping of needles by a 2-handed technique).
OSHA requires employers to use PPE as a control to reduce employee exposure to hazards when engineering and administrative controls are not feasible or effective.
PPE IN DENTISTRY
The CDC in its 2003 Infection Control Guidelines for Dentistry also addresses the issue of PPE.2 The CDC indicated that PPE is designed to protect the skin and the mucous membranes of the eyes, nose, and mouth of DHCP from exposure to blood or other potentially infectious materials. The CDC recommends when, what, and how to use PPE.
Use of rotary dental and surgical instruments (eg, handpieces or power scalers) and air-water syringes creates a visible spray that contains primarily large-particle droplets of water, saliva, blood, microorganisms, and other debris. This spatter travels only a short distance and settles out quickly, landing on the floor, nearby operatory surfaces, DHCP, or the patient. The spray also might contain certain aerosols (eg, particles less than 10 µm in diameter). Aerosols can remain airborne for extended periods and can be inhaled. However, they should not be confused with the large-particle spatter that makes up the bulk of the spray from handpieces and ultrasonic scalers. Appropriate work practices, including use of dental dams and high-velocity air evacuation, should minimize dissemination of droplets, spatter, and aerosols.
Primary PPE used in oral healthcare settings includes gloves, surgical masks, protective eyewear, face shields, and protective clothing (eg, gowns and jackets). All PPE should be removed before DHCP leave patient care areas. Reusable PPE (eg, clinician or patient protective eyewear and face shields) should be cleaned with soap and water, and when visibly soiled, disinfected between patients according to the manufacturer’s directions.
Wearing gloves, surgical masks, protective eyewear, and protective clothing in specified circumstances to reduce the risk of exposures to bloodborne pathogens is mandated by OSHA. General work clothes (eg, uniforms, scrubs, pants, and shirts) are not intended to protect against a hazard and should not be considered PPE.1-5
PPE—TYPES AND SELECTION FACTORS
There are 5 basic types of PPE used in healthcare settings1,7-9:
(1) gloves—protect hands,
(2) gowns/aprons—protect skin and/or clothing ,
(3) masks and respirators—protect mouth and nose (respirators also protect the respiratory tract from airborne infectious agents),
(4) spectacles/goggles—protect eyes, and
(5) face shields—protect face, mouth, nose, and eyes.
A number of factors influence PPE selection. These include the following:
(1) type of exposure anticipated (splash/spray versus touch or category of isolation precautions),
(2) allergies and sensitivities (to PPE construction materials),
(3) design and features,
(4) durability (including shelf life),
(5) appropriateness for the task,
(6) sizing or fit (comfort), and
(7) cost effectiveness.
Compliance concerning PPE often depends on personal preferences. However, increased comfort (better fit, ergonomics, allergies, and body temperature regulation) usually translates into higher levels of compliance.
WHY WEAR PPE?
The goal of wearing PPE is to protect DHCP from occupationally related diseases. Disease can spread through 4 main ways in the dental practice environment.1-3 PPE is designed to interfere with each of the 4 pathways—direct contact, indirect contact, droplet infection, and airborne infection via inhalation (Table).
| Table. Preventing Disease Spread Through the Use of PPE.* | |||||||||||||||
*From References 1 and 3. |
GLOVES
Intact skin is an effective barrier against microorganisms. However, hands can have invisible defects, especially around the fingernails. Treat-ment of dental patients af-fords ample opportunity for DHCP hands to come into contact with microorganisms.
Gloves protect both DHCP and patients. Four types of gloves are used in dental settings1-3,7-9:
(1) patient examination gloves (nonsterile, nonsurgical, single-use)
(2) surgical gloves (sterile, surgeon, single-use)
(3) utility gloves (heavy duty, reusable)
(4) heat resistant gloves (reusable).
There are several considerations when selecting gloves, and their composition is very important. The most common materials used include natural latex rubber (NLR), vinyl, nitrile, neoprene, and poly-urethane. Other physical characteristics and considerations include fit, cuff length, cuff type, color, smell, texture, powder/powder-free, and cost.
For all PPE, a proper fit is essential; maximum protection requires correct fit. Better fitting PPE is more acceptable to wearers; thus, comfort equals compliance.
PPE such as gloves are used to protect; however, there are instances when wearing PPE becomes problematic. Use may result in adverse reactions. DHCP must always be able to identify symptoms associated with these reactions and then be able to respond effectively.
Chemicals in the gloves can cause adverse reactions.7-10 The most common reaction is irritant contact dermatitis (ICD), which is a condition due to nonimmunologic irritation from chemicals. ICD presents as dry, itchy, irritated areas of skin around the zone of contact with the offending agent. ICD compromises healthy skin and in-creases the chances of materials entering the blood stream. Several behaviors aggravate ICD: (1) failure to wash hands after removing gloves; (2) not rinsing thoroughly after handwashing; (3) not drying hands completely before donning gloves; and (4) contact with irritating hand cleaners.
Allergic contact dermatitis (ACD) is a skin reaction that occurs after contact with chemicals that serve as allergens and stimulate a cell-mediated immune response. ACD, unlike ICD, involves an immunological response, which is often called “delayed hypersensitivity” or “type IV hypersensitivity.” A nondental example involves the allergic oils present in poison ivy plants.
Immediate hypersensitivity is another type of im-munological reaction, which involves an antibody re-sponse. Latex is an allergen involved with the adverse response. Immediate hypersensitivity can be serious, sometimes even life-threatening, and is also called type I hypersensitivity.
Gowns/Aprons
Protective clothing such as gowns and aprons cover skin, street clothes, and uniforms, preventing contamination from emitted droplets, splashes, and debris. Under-lying clothes are not intended to protect against a hazard and are not proper PPE. Protective clothing may be disposable or reusable. Pro-tective apparel must be changed when it becomes visibly soiled. The change should be immediate when there is penetration by blood or patient body fluids. Ideally, protective clothing is fluid resistant. Appropriate-ness is the balance of protection and comfort (fabrics that “breathe”).1-3,7-9
The 2003 CDC Guidelines recommend that protective clothing covers the forearms and underlying clothing. Ideally, protective clothing has long sleeves and high necks, and covers the lap when the wearer is seated.3
The recycling of reusable gowns and aprons is the responsibility of the employer. Practices should determine cost-effectiveness by comparing costs of disposable versus reusable apparel or using an outside laundry versus an in-office washer and dryer.
Masks
Masks are worn by DHCP for 2 reasons. Surgical masks are primarily worn to protect mucous membranes against patient oral fluids in the form of droplets and spatter. A second benefit is to minimize inhalation of aerosols generated during patient treatment. The masks usually worn by DHCP are surgical masks, not respirators. To-day’s masks are very efficient but are not designed to protect against diseases such as tuberculosis.1-3,7-12
Proper fit is essential for masks. They should fit comfortably over the nose and mouth with no gaps on the sides. Always be aware that some DHCP may become allergic or in some way sensitive to a certain type of mask.
Masks are single-use, disposable PPE; they are not to be worn again when treating subsequent patients, nor are they to be pulled down. Once in place, masks are not to be touched unless they are to be removed. Masks quickly lose their filtering abilities when they become moistened by the wearer’s breath and/or by the buildup of patient oral fluids.
It is important to know the filtration ratings of the masks being used, both the bacterial filtration efficiency (BFE) and particulate filtration efficiency (PFE). BFE describes the exclusion rate of bacteria, which are 1 to 5 µm. PFE measures mask filtering of inorganic particles, which are 0.1 to 1.0 µm in size.
Acceptable masks have a filtration rate of 95%. How-ever, many masks today have filtration efficiencies ap-proaching 99%. Can the filtration action be too much? Another measure of masks is breathability (Delta P), which measures the drop in pressure across a mask. The higher the Delta P value, the greater the retention of materials; but it also means it is more difficult to breathe through the mask.
Eye Protection
Spectacles with side shields or face shields protect the wearer from patient oral fluids, expelled projectiles, and hazardous chemicals. Almost all spectacles and safety goggles sold today have the impact resistance needed for dentistry.1-3,7-10
Proper face protection includes masks and protective eyewear or chin length face shields. Protective eyewear should be provided to patients to protect their eyes during treatment.
Protective eyewear be-comes readily soiled during treatment. This PPE can be cleaned with soap and water if not contaminated by blood. Use an intermediate-level disinfectant when blood is visible. Be sure to rinse the spectacles or face shields well after cleaning and disinfection.
DONNING PPE
The CDC has described a sequence for donning PPE.7 For dentistry the following order should be used:
(1) gown/apron first,
(2) mask,
(3) spectacles, goggles, or face shields, then
(4) gloves.
The following issues should be addressed when donning a gown or apron:
(1) select appropriate type and size,
(2) opening usually should be in the back, and
(3) secure neck and waist.
The following issues should be addressed when donning a mask:
(1) place over nose, mouth, and chin,
(2) fit flexible nose piece over bridge of the nose,
(3) secure on head with ties or elastic, and
(4) adjust fit.
The following issues should be addressed when donning eye protection:
(1) position spectacles or goggles over eyes and secure to the head using the ear pieces or headband
(2) position face shield over the face and secure on brow with headband
(3) adjust to fit comfortably.
The following issues should be addressed when donning gloves:
(1) don gloves last,
(2) select correct type and size,
(3) insert hands into gloves, and
(4) extend hands over isolation gown cuffs.
REMOVING PPE
The CDC has described a sequence for removing PPE.7 For dentistry the following order should be used:
(1) gloves,
(2) spectacles, goggles, or face shield,
(3) gown, and
(4) mask.
The following issues should be addressed when removing gloves:
(1) grasp outside edge near wrist,
(2) peel away from hand, turning glove inside-out,
(3) hold in opposite gloved hand,
(4) slide ungloved finger under the wrist of the remaining glove,
(5) peel off from inside, creating a bag for both gloves, and
(6) discard.
The following issues should be addressed when removing eye protection:
(1) grasp ear or head pieces with ungloved hands,
(2) lift away from face, and
(3) place in designated receptacle for reprocessing (cleaning or disinfection) or disposal.
The following issues should be addressed when removing gowns:
(1) unfasten ties,
(2) peel gown away from neck and shoulder,
(3) turn contaminated outside toward the inside,
(4) fold or roll into a bundle, and
(5) discard.
The following issues should be addressed when removing masks:
(1) untie the bottom, then the top,
(2) pull off elastic bands, and
(3) remove and discard.
FINAL THOUGHTS ON USE OF PPE
Consider that used PPE has 2 sides—contaminated and clean areas.7 Contaminated areas are on the front or outside. These are areas of PPE that have or are likely to have been in contact with body fluids, patient tissues, soiled materials, or environmental surfaces. Clean areas are on the inside, outside back, or ties on the head or back. These are areas that are not likely to have been in contact with patient body fluids or tissues.
After completion of treatment, perform hand hygiene immediately after removing PPE. The same is true when replacing gloves that become defective during treatment.
The types of the PPE used are influenced by the nature of the activity and the risk of exposure. The actual styles selected should be a joint effort of all DHCP working in the practice.
References
1. Miller CH, Palenik CJ. Infection Control & Management of Hazardous Materials for the Dental Team. 3rd ed. St Louis, Mo: Mosby Year Book; 2005:260-275.
2. Kohn WG, Collins AS, Cleveland JL, et al; Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings: 2003. MMWR Recomm Rep. 2003;52(RR-17):1-61.
3. Organization for Safety and Asepsis Procedures. From Policy to Practice: OSAP’s Guide to the Guidelines. Annapolis, Md: OSAP; 2004:45-62.
4. Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens – OSHA. Final rule. Fed Regist. 1991;56(235):64004-64182.
5. Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens; needlestick and other sharps injuries; final rule. Fed Regist. 2001;66:5318-5325.
6. Palenik CJ. Preventing cross-contamination and disease transmission. Contemp Dent Assist. 2005;2:34-38.
7. Centers for Disease Control and Prevention. Personal protective equipment (PPE) in healthcare settings. Available at: http://www.cdc.gov/ncidod/hip/ppe/default.htm. Accessed September 2005.
8. Miller CH. Be prepared: a PPE primer, Part I. Dental Products Report. 2004;38:52-55.
9. Palenik CJ. Selection and use of PPE. Dent Equip & Materials. 2005;10(2):62-63.
10. Miller CH. Be prepared: a PPE primer, Part II. Dental Products Report. 2004;38:54-57.
11. Hughes E, Palenik CJ. Proper use and selection of masks. Dent Equip & Materials. 2005;10(2):68-69.
12. Hughes E, Palenik CJ. Behind the mask. RDH. 2004;24(9):72,74,76,78.
Dr. Palenik has held over the last 25 years a number of academic and administrative positions at Indiana University School of Dentistry. These include professor of oral microbiology, director of human health and safety, director of central sterilization services, and chairman of infection control and hazardous materials management committees. Currently he is director of infection control research and services. Dr. Palenik has published 175 articles, more than 305 monographs, 3 books, and 7 book chapters, the majority of which involve infection control and human safety and health. Also, he has provided more than 100 continuing education courses throughout the United States and 8 foreign countries. All questions should be directed to OSAP at office@osap.org.
