PPE is designed to protect the skin and the mucous membranes of the eyes, nose and mouth of DHCP from exposure to blood or OPIM. Use of rotary dental and surgical instruments (eg, handpieces or ultrasonic 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 (ie, particles of respirable size, <10 μm). Aerosols can remain airborne for extended periods and can be inhaled. 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). Wearing gloves, surgical masks, protective eyewear and protective clothing in specified circumstances to reduce the risk of exposures to blood-borne pathogens is mandated by OSHA. Masks, Protective Eyewear, Face Shields

A surgical mask should cover both the nose and mouth. It should be able to filter >95% of bacteria (eg, N95, N99 or N100), particularly if infection isolation precautions are necessary. The mask’s outer surface can become contaminated with infectious droplets from spray of oral fluids or from touching the mask with contaminated fingers. When a mask becomes wet from exhaled moist air, the resistance to airflow through the mask increases. Available data indicate infectious droplet nuclei measure 1 to 5 μm; therefore, respirators used in healthcare settings should be able to efficiently filter the smallest particles in this range. This causes more airflow to pass around edges of the mask.

The eyes should be protected from debris or large particles of water containing blood and OPIM. Eye protection wear should be designed with side shield or, better still, face shields.

RECOMMENDATIONS:

1. Wear a surgical mask and eye protection with solid side shields or a face shield to protect mucous membranes of the eyes, nose and mouth during procedures likely to generate splashing or spattering of blood or other body fluids.
2. Change masks between patients or during patient treatment if the mask becomes wet.
3. Clean with soap and water, or if visibly soiled, clean and disinfect reusable facial protective equipment (eg, clinician and patient protective eyewear or face shields) between patients.
4. All PPE should be removed before DHCP leave patient-care areas.
5. 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.

Protective Clothing

Protective clothing and equipment (eg, gowns, lab coats, gloves, masks, and protective eyewear or face shield) should be worn to prevent contamination of street clothing and to protect the skin of DHCP from exposures to blood and body substances. OSHA blood-borne pathogens standard requires sleeves to be long enough to protect the forearms when the gown is worn as PPE (ie, when spatter and spray of blood, saliva or OPIM to the forearms is anticipated).

RECOMMENDATIONS:

1. Wear protective clothing (eg, reusable or disposable gown, laboratory coat or uniform) that covers personal clothing and skin (eg, forearms) likely to be soiled with blood, saliva, or OPIM.
2. Change protective clothing if visibly soiled.
3. Change immediately or as soon as feasible if penetrated by blood or other potentially infectious fluids.
4. Remove barrier protection, including gloves, mask, eyewear and gown before departing work area (eg, dental patient care, instrument processing or laboratory areas).

Gloves and Gloving

DHCP wear gloves to prevent contamination of their hands when touching mucous membranes, blood, saliva or OPIM, and also to reduce the likelihood that microorganisms present on the hands of DHCP will be transmitted to patients during surgical or other patient care procedures.

Wearing gloves does not eliminate the need for handwashing. Hand hygiene should be performed immediately before donning gloves. Gloves can have small, unapparent defects or can be torn during use, and hands can become contaminated during glove removal. These circumstances increase the risk of operative wound contamination and exposure of the DHCP’s hands to microorganisms from patients. In addition, bacteria can multiply rapidly in
the moist environments underneath gloves, and thus, the hands should be dried thoroughly
before donning gloves and washed again immediately after glove removal.

Types of Gloves

Because gloves are task-specific, their selection should be based on the type of procedure to be performed (eg, surgery or patient examination). Sterile surgeon’s gloves must meet standards for sterility assurance established by FDA and are less likely than patient examination gloves to harbor pathogens that could contaminate an operative wound. Appropriate gloves in the correct size should be readily accessible.

Glove Integrity

Consistent with observations in clinical medicine, leakage rates vary by glove material (eg, latex, vinyl and nitrile), duration of use and type of procedure performed, as well as by manufacturer. The frequency of perforations in surgeon’s gloves used during outpatient oral surgical procedures has been determined to range from 6% to 16%.

Studies have demonstrated that HCP and DHCP are frequently unaware of minute tears in gloves that occur during use. These studies determined that gloves developed defects in 30 minutes to 3 hours, depending on type of glove and procedure.

Materials that come in contact with the gloves during dental procedures can affect the integrity of the gloves. The glove material may also affect the properties of the materials used. Latex, for instance, can affect the setting of polysiloxane impression material. The setting is apparently not affected by synthetic vinyl gloves.

If the integrity of a glove is compromised (eg, punctured), it should be changed as soon as possible. Washing latex gloves with plain soap, chlorhexidine or alcohol can lead to the formation of glove micro punctures (wicking) and subsequent hand contamination. After a hand rub with alcohol, the hands should be thoroughly dried before gloving, because hands still wet with an alcohol-based hand hygiene product increase the risk of glove perforation.

FDA regulates the medical glove industry, which includes gloves marketed as sterile surgeon’s and sterile or non-sterile patient examination gloves. More rigorous standards are applied to surgeon’s than to examination gloves.

RECOMMENDATIONS:

1. Wear medical gloves when a potential exists for contacting blood, saliva, OPIM or mucous membranes.
2. Wash hands thoroughly prior to donning of gloves.
3. Wear a new pair of medical gloves for each patient, remove them promptly after use then wash hands immediately to avoid transfer of microorganisms to other patients or environments.
4. Remove gloves that are torn, cut or punctured as soon as feasible and wash hands before regloving.
5. Do not wash surgeon’s or patient examination gloves before use or wash, disinfect, or sterilize gloves for reuse.
6. Ensure that appropriate gloves in the correct size are readily accessible.
7. Use appropriate gloves (eg, puncture- and chemical-resistant utility gloves) when cleaning instruments and performing housekeeping tasks involving contact with blood or OPIM.
8. Consult with glove manufacturers regarding the chemical compatibility of glove material and dental materials used.

Sterile Surgeon’s Gloves and Double-Gloving during Oral Surgical Procedures

There is apparently no difference in post-operative infection rates after routine extractions when the surgeon wears sterile or non-sterile gloves. The greater issue is the transmission of infection from DHCP to the patient and vice versa. Since sterile gloves are more rigorously regulated they may offer an increased level of protection when exposed to blood and OPIM.

RECOMMENDATIONS:

1. Wear sterile surgeon’s gloves when performing oral surgical procedures.
2. No recommendation is offered regarding the effectiveness of wearing two pairs of gloves to prevent disease transmission during oral surgical procedures. The majority of studies among HCP and DHCP have demonstrated a lower frequency of inner glove perforation and visible blood on the surgeon’s hands when double gloves are worn; however, the effectiveness of wearing two pairs of gloves in preventing disease transmission has not been demonstrated (Unresolved issue).

Contact Dermatitis and Latex Hypersensitivity

Contact dermatitis and latex hypersensitivity are conditions associated with the use of latex gloves. Contact dermatitis often manifests hours after exposure and is usually confined to the areas of contact.

Latex hypersensitivity on the other hand (type 1 hypersensitivity to latex) can result in more serious systemic allergic reactions. This usually begins within minutes of exposure. This may manifest as runny nose, sneezing, itchy eyes, scratchy throat, hives or itchy burning sensations. More severe reactions may include difficulty in breathing, coughing spells and wheezing. Cardiovascular and gastrointestinal ailments may also manifest and in extremely rare instances, anaphylaxis and death.

Natural rubber latex proteins responsible for latex allergy are attached to glove powder. When powdered latex gloves are worn, more latex protein reaches the skin. Also, when removing these powdered gloves, the powder can be released into the air and be inhaled or come in contact with mucous membranes. The DHCP can become sensitized with repeated exposure to latex protein. The DHCP should be provided with reduced protein, powder-free gloves. Nonlatex gloves are also available. It should be mentioned that while life-threatening reactions are rare, the DHCP must be prepared to cope with these emergencies.

RECOMMENDATIONS:

1. Educate DHCP regarding the signs, symptoms and diagnoses of skin reactions associated with frequent hand hygiene and glove use.
2. Screen all patients for latex allergy (eg, take health history and refer for medical consultation when latex allergy is suspected). DHCP must be informed of patients with latex allergy.
3. Ensure a latex-safe environment for patients and DHCP with latex allergy by cleaning all work areas contaminated with latex dust.
4. Have emergency treatment kits with latex-free products available at all times.