Correctly using personal protective equipment (PPE) is the difference between helping or hindering every day dental practice. What does it mean to utilize PPE to optimize infection control?
As ubiquitous as personal protective equipment (PPE) is, sometimes confusion and bad habits can lead to incorrect usage, rendering it useless. On the surface, putting on a mask, a pair of gloves, or a gown may seem foolproof. However, there are specific ways in which those pieces of protective gear need to be worn. Sometimes the specifics are misunderstood or overlooked by team members, so a refresher can be helpful.
It all starts by knowing which pieces of protective equipment must be worn.
“The basic or the essential components of PPE are: eye protection, mask, an appropriate jacket or gown, and gloves,” Linda Harvey, RDH, MS, LHRM, DFASHRM, says. Harvey is the president and founder of The Linda Harvey Group, a healthcare compliance and risk management consulting company. “Those have always been the core components of PPE. How we select what we select is very important, but first let’s go back and revisit why we’re wearing PPE. The reason that we started wearing PPE throughout healthcare is when OSHA’s Bloodborne Pathogen Standard became effective in 1992. That standard mandated PPE to protect all healthcare workers against contracting a bloodborne disease in the workplace, such as HIV, hepatitis B, and hepatitis C. Since that time, the type and quality of PPE, has really evolved, and so have the standards regarding what each of those components of PPE should consist of.”
“Whenever there’s potential for spatter or splatter or exposure to blood or other potentially infectious materials, healthcare professionals, and that includes dental, are supposed to wear gloves,” infection prevention speaker, author, and consultant Mary Govoni,CDA, RDH, MBA adds. “They also need eye protection, which has kind of been redefined over the pandemic. Respiratory protection like face masks have sort of been redefined over the pandemic, as well as protective clothing. Protective clothing means that you wear something over your street clothing or your scrubs that protects you from spatter and splatter and aerosols. OSHA considers it something like a lab coat or a surgical gown. It could be reusable, or it could be a disposable. Scrubs, of course, typically have short sleeves, and some people will wear scrubs with a long sleeve t-shirt or some kind of a long sleeve piece of clothing underneath to protect their arms. But that doesn’t meet the OSHA requirement.”
OSHA isn’t the only organization with something to say about PPE. The American National Standards Institute (ANSI) sets the bar for eyewear safety standards.
“They create the standards for eyewear that OSHA then implements,” Harvey elaborates. “Last year, the eyewear standards changed because it was recognized that there was insufficient undereye protection in general for all healthcare professionals for general professionals – and probably for all professionals – because it’s changed, and ANSI impacts everybody. Since that time, we can no longer wear our prescription glasses with side shields, nor can we wear traditional safety goggles. We have to wear safety goggles that are kind of the molded around your face so there’s no gap under your eye, over your eye, and onto the sides. If you’re not wearing goggles, then you should wear a full face shield that comes down to at least your chin or below your chin.”
Respiratory protection is probably the most visible sign of team member safety, and not just any mask will do. Team members have several different types of masks and respirators from which to choose. The appropriate protective gear depends on the procedure being performed and any guidance from authorities like OSHA or CDC.
“The levels have to do with a whole bunch of criteria, but the two key criteria that we look for in dentistry are the particle filtration size and fluid resistance,” Govoni says. “Fluid resistance is really important, because for any viral particles or aerosol particles to get through the mask, they’re going to be drawn into the mask. When somebody breathes in with some fluid, they’re going to be attached to water or saliva that’s produced when using a handpiece or an ultrasonic scaler.
“But the biggest difference,” she continues, “between like wearing a Level 3 mask, which gives you the highest level of particle filtration and fluid resistance, and a respirator has an even higher level of fluid resistance, and it seals around the face. It’s kind of the same issue as wearing safety glasses versus goggles. Something can get in underneath the glasses or breathe in through the face mask. If someone wears a face mask, they typically gap on the sides and they don’t seal. So, you could actually breathe in some aerosol particles, whereas an N95 respirator actually seals around the face, so nothing gets in, and you breathe in solely through that material of the respirator.”
Donning and Doffing
An area where team members may advertently trip up is putting on and removing (also known as donning and doffing) PPE.
“It is an issue in dentistry, because I think that we become engrossed in our daily schedules, and keeping up with the workflow,” Harvey says. “And as a result, we just quickly take off the PPE, and maybe the patients in a hurry to leave or whatnot, and we need to keep moving the schedule forward. So, I think there’s not enough thought given to that throughout the day to ensure that someone is doing it properly. The last piece of PPE that you put on is your gloves. Once you put on your gloves, you should not be adjusting your mask, your hair, your glasses. Many times, team members will say to me, ‘What’s the big difference if I touch this or touch that?’ Well, that’s true, but we don’t want to contaminate the gloves any further. And we know the oral cavity is not sterile either, but the patients are watching us and they are curious and they want to see good practice, and why do we want to interject more contamination into the oral cavity by touching items and objects that we shouldn’t during patient care? So, the last thing that goes on is your gloves.
“When you’re donning the gloves, that’s where you want to be sure that they cover over your wrist,” she continues. “So ideally, your jacket should have cuffs that protect your wrists, and the gloves should go over the cuff, so that way there’s no skin exposed during the patient procedure.”
But the correct procedure shouldn’t be confusing. For DHCP who just aren’t sure whether they are doing the process properly (or just for a general refresher) CDC can help demystify the process
“The CDC has excellent resources for donning and doffing of PPE,” Govoni says. “They have some training videos that you can watch. And they have posters that could be put up in a dental practice that show you the donning and doffing process. The biggest mistake I see with donning and doffing is people leaving the treatment room with contaminated gloves on. When they’re finished with treatment, they need to take off their gloves and they need to wash their hands, because there could be some leakage that they’re not aware of through their gloves onto their hands. And alcohol hand sanitizer isn’t going to clean any of that debris off. It’s not a good cleaner.”
PPE really became a dental staple in the early 1990s on the heels of the AIDS epidemic. More recently, additional focus was put on PPE following the COVID-19 pandemic.
“It’s been respiratory protection, wearing a higher-level face mask, a Level 3, and an N95 respirator, because it’s better protection from aerosols, and then eye protection,” Govoni says. “In the past, just under the Bloodborne Pathogen Standard, OSHA would consider safety glasses with side shields to be adequate eye protection. But during the pandemic, when we knew that aerosols could get up underneath some of those safety glasses, OSHA began to recommend wearing goggles or face shields. Well, goggles are very uncomfortable. They do seal around the face, true, but they’re not comfortable to wear. The face shields are much better, and we’re seeing even better and better face shields.”
“There have been several changes in the PPE best practices,” Harvey adds. “For example, many dental teams never considered wearing head covers before. Head covers are good options for protecting your hair, your head from spray and splatter throughout the day, because up until the pandemic, there was not much thought given to that. In most general practices, the bonnets or head caps may have been worn in surgical procedures, but not routinely in a general practices. And I see more teams still wearing them just because they enjoy the extra protection and peace of mind from the head cap.”
Mistakes happen. It’s regrettable, but also preventable. Some of the most common errors can be prevented with a little bit of knowledge.
“The number one thing they do wrong is they reuse their face masks or their respirator,” Govoni says. “Now, during the middle of the pandemic, when face masks and respirators were in short supply, the FDA issued emergency use authorizations where those items could be reused, but because we were in a crisis supply management situation, and those have all expired, they’re not in effect anymore. Even before the pandemic, a lot of people would put a face mask on at the beginning of the day, and in between patients, they would slide it down underneath their chin or hang it off one ear and walk around with that and keep reusing it. Face mask filtration is good, for at maximum protection, for about 45 minutes or so. Face masks are disposable items, and during a long procedure, they should maybe even be a change of a face.”
Team members should also be aware of how protective equipment may be hindered by personal accessories.
“Jewelry should not be worn, because in addition to trying to keep them underneath your jacket, they could become entangled with a jacket or mask when you’re donning and doffing the PPE,” Harvey says. “And it’s difficult to wash your hands when you have bracelets dangling around.”
Gloves must be worn and removed appropriately.
“Another red flag is not taking their gloves off before they leave the treatment room,” Govoni says. “So now that we’re not in the aerosol precautions that we were in the beginning of the pandemic, we don’t have to change our protective equipment, our clothing, after every patient. They can put on a gown, or a lab coat on in the morning, and as long as it’s not visibly soiled with blood, they can wear it for an entire day. There still is a risk of cross-contamination when they’re seeing patients, they are getting aerosols on that gown, and they may touch it. They wear it into the break room and wear the contaminated gown while eating or drinking. Contaminated clothing should never be worn in the breakroom.”
Masks are also commonly misunderstood and must be used correctly.
“Sometimes they still want to wear their mask down either right to the edge of their nose or right below their nose,” Harvey says. “In some cases, we’ve got some offices that we’ve seen that have reverted back to old habits, because they don’t feel like they can breathe, or their mask fogs up their glasses. That’s something that can be resolved by trying different types of PPE, a different face shield or a different set of goggles, a different mask. When a team member or doctor wears their mask under their nose, they’re most definitely inhaling all the aerosols, all the spray, all the splatter and all the contamination that’s in the air during that procedure.”
PPE is necessary for team member and patient safety. However, if it is not worn appropriately, it provides limited, if any, protection at all.