Creating a Barrier Between People and Microbes
PPE is a critical element of standard precautions for infection control.
Personal protective equipment (PPE) is an essential element of infection control in oral healthcare delivery. Potentially infectious microorganisms may be present in the oral fluids of patients, in the body fluids or on the hands of dental healthcare personnel (DHCP), and on environmental surfaces. Disease transmission has the potential to occur from direct contact with infectious materials or indirect contact with contaminated surfaces and equipment.1 A combination of infection control procedures called standard precautions, of which PPE is one element, is needed to ensure a safe oral healthcare environment for the patient and a safe working environment for DHCP.
Prior to 1996, the Centers for Disease Control and Prevention (CDC) recommended that all blood and certain body fluids likely to contain blood be considered potentially infectious for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other bloodborne diseases.
These universal precautions were updated and expanded in 1996 by the CDC, replacing them with standard precautions.2 According to the CDC, "Standard precautions integrate and expand the elements of universal precautions into a standard of care designed to protect HCP and patients from pathogens that can be spread by blood or any other body fluid, excretion, or secretion. Standard precautions apply to contact with 1) blood; 2) all body fluids, secretions, and excretions (except sweat), regardless of whether they contain blood; 3) nonintact skin; and 4) mucous membranes. Saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between universal precautions and standard precautions."1
Simply put, standard precautions dictate that infection control practices should be the same for all patients regardless of their known infectious disease status. Differences in protocols may be indicated based on procedural differences (eg, simple oral examination vs. oral surgery), but should be consistently applied for a given procedure each time any patient is treated. By using standard precautions, DHCP are ensuring that patients and personnel are provided the suitable level of safety during every dental procedure.
Regulations and Recommendations
The Occupational Safety and Health Administration (OSHA) is the government agency charged with protecting the health and safety of all workers in the United States. One of the many regulations this agency enforces is the Bloodborne Pathogens Rule, dealing with infection control in healthcare settings. The Bloodborne Pathogens Rule requires the use of appropriate PPE, and also requires that the employer provide, maintain, and replace PPE as needed.3 PPE includes gloves, masks, eye protection, and protective garments. OSHA also includes items such as resuscitation bags, face masks, or other ventilation devices in their requirements for PPE in the event direct contact with the patient may be necessary during a medical emergency.
The nature of OSHA regulations is such that it is the employer's responsibility to ensure that employees use PPE where indicated. This means that not only does the employer have to provide gloves, masks, eye protection, and protective clothing, they must ensure that employees with occupational exposure to body fluids wear these items when there is the potential for exposure.
The CDC is a branch of the US Department of Health and Human Services and, as such, makes recommendations intended to promote public health. The CDC has guidelines that are specific to infection control in dentistry, as well as many general infection control topics, such as disinfection and sterilization, prevention of bloodborne disease transmission in healthcare settings and others that apply to all healthcare settings. These guidelines do not carry the weight of law, but are frequently the basis for infection control regulations by agencies such as OSHA or state boards of dentistry.
Gloves
Although not widely used in oral healthcare until the mid-1980s, the use of medical gloves for all dental procedures is now routine for oral healthcare delivery in the developed world. Gloves are made of a variety of materials including latex, polyvinyl, nitrile, chloropene, and many other materials and combinations of synthetic and natural products (Figure 1). There are two grades of gloves: medical examination gloves and sterile surgical gloves. The selection of which grade of glove to use depends on the type of procedure to be performed.1
Medical Examination Gloves
Routine dental procedures require only the use of nonsterile examination gloves. Medical examination gloves are nonsterile, packed in boxes of multiples, and are usually not hand-specific (ie, packaged in pairs intended for the right and left hand). Gloves are intended for the protection of the patient as well as the DHCP. Gloves prevent the DHCP from having bare-handed contact with a patient's oral fluids, but also serve as a barrier between contaminants on the DHCP's hands and the patient's oral mucosa. Gloves should be the last item of PPE the DHCP dons before treating patients, to avoid inadvertently contaminating the gloves before initiating treatment. After performing hand hygiene and then placing gloves, nothing should be touched with gloved hands except the patients' oral tissues and patient care equipment. OSHA prohibits washing or decontaminating gloves for re-use.3 Hand hygiene should be performed again after removal of gloves because inadvertent contamination of hands can occur due to small breaks in the glove material or while removing gloves.
Sterile Surgical Gloves
Sterile gloves are indicated for use when performing surgical procedures. Oral surgical procedures expose the vascular system and other normally sterile tissues to the numerous organisms that normally colonize in the oral cavity.1 Sterile surgical gloves should be worn for procedures such as surgical extractions, periodontal surgery, tissue grafting, and other procedures that involve incision, ablation, or excision of hard and soft tissues.4
Hand Care
Frequent hand washing, exposure to chemicals, and glove use can lead to hand irritation and contact dermatitis. The most common type of dermatitis related to these is irritant contact dermatitis, which develops as dry, itchy, irritated areas on the skin of the fingers or other surfaces of the hand. Individuals may also experience allergic contact dermatitis, which is related to exposure to irritating chemicals such as those used in the manufacturing of latex and in certain disinfectants. Rarely, but more seriously, individuals may develop a latex allergy, which can result in anything from hives, itchy eyes, runny nose, and other common allergy symptoms to more serious symptoms including asthma, wheezing, and even anaphylaxis.5 Contact dermatitis and latex allergy are medical conditions that should be evaluated by a qualified healthcare professional.
In order to keep skin healthy and intact, hand lotions may be used throughout the day to prevent dry skin, which can lead to irritation and breaks in the skin's surface. However, lotions that contain petroleum or other oil-based products should be avoided, except at the end of the day.6
Masks and Eye Protection
Surgical masks were originally adopted to prevent infections of surgical wounds by attending medical providers.7 Masks are now widely used as a means of protecting healthcare workers' oral and nasal mucosa from contamination with aerosols or spatter generated during patient care. A surgical mask and protective eyewear with solid side shield or a face shield should be worn by DHCP during procedures likely to generate splashes or droplets of blood or body fluids. The protection should provide coverage to the mucous membranes of the eyes, nose, and mouth. A surgical mask protects against smaller aerosolized particles and also larger particle droplets that may occur during the use of dental equipment such as handpieces, ultrasonic scalers, and air/water syringes.
Because a mask's outer surface may become contaminated from contact with droplets generated during treatment or from touching by the DHCP, the mask should be changed between patients to prevent cross-contamination. Additionally, when a mask becomes wet from moisture in the DHCP's exhaled air, its ability to perform filtration is compromised. Therefore, if the mask becomes wet, it should be changed during patient treatment, when possible.1 A surgical mask is not a respirator and is not considered adequate protection against certain airborne disease such as tuberculosis, chicken pox, and measles, among others.2
Gowns and Lab Coats
Street clothes, work clothes, and skin may all be vulnerable to contamination during dental procedures. In addition to gloves and face protection, it is usually necessary to wear a gown or lab coat that will protect clothing and intact skin from contact with blood or other oral fluids during dental procedures. Some OSHA-specific requirement related to protective clothing include that the employer provide all PPE and ensure its use by employees with occupation exposure to blood and other potentially infectious materials (OPIM). The employer must also arrange to have attire laundered or disposed, preventing the employees from taking potentially contaminated garments home where contamination may spread to the home environment.3 Because dental procedures often involve spray or aerosol from devices held in the DHCP's gloved hands, long sleeves on protective garments are necessary to prevent contamination of the skin or clothing on the DHCP's forearms (Figure 2).
Conclusion
Personal protective equipment is a critical element of standard precautions and must be used in combination with other infection control procedures. Improper use or selection of PPE can result in potential cross-contamination between patients and DHCP and the oral healthcare environment. PPE should be selected based on the anticipated exposure, which may vary depending on the type of dental procedure.
References
1. Belkin NL. A century after their introduction, are surgical masks necessary? AORN J. 1996;64(4):602-607.
2. Kohn WG, Collins AS, Cleveland JL, et al. Guidelines for infection control in dental health-care settings, 2003. MMWR. 2003;52(RR-17):1-61.
3. Occupational Safety and Health Administration, US Department of Labor. Bloodborne pathogens. Occupational Safety and Health Standards—Toxic and Hazardous Substances. 29 CFR Part 1910.1030. 3. Available at: www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10051.
4. Occupational exposure to bloodborne pathogens, needlesticks and other sharps injuries; final rule. Federal Register. 2001;66:5317-5325. [As amended from and includes 29 CFR Part 1910:1030. Occupational exposure to bloodborne pathogens; final rule. Federal Register. 1991;56:64174-63182.]
5. Garner JS. Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol. 1996;17(1):53-80.
6. Mangram AJ, Horan TC, Pearson ML, et al. Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
7. Hunt LW, Fransway AF, Reed CE, et al. An epidemic of occupational allergy to latex involving health care workers. J Occup Environ Med. 1995;37(10):1204-1209.
8. Larson EL. APIC guideline for hand washing and hand antisepsis in health-care settings. Am J Infect Control. 1995;23(4):251-269.
About the Author
Eve J. Cuny, RDA, MS
Assistant Professor, Dental Practice
Director, Environmental Health and Safety
University of the Pacific
Arthur A. Dugoni School of Dentistry
San Francisco, California
