Selection and use of personal protective equipment.

The 2003 CDC Guidelines for Infection Control in Dental Health Care Settings recommend that Standard Precautions be practiced while delivering dental treatment to all patients. These precautions include practices and procedures that integrate and expand the elements of universal precautions. The result is a standard of care designed to protect health care workers and patients from pathogens that can be spread by blood or any other body fluids. Saliva has always been considered a potentially infectious material in dental infection control.

The United States Occupational Safety and Health Administration (OSHA) indicates that protection of dental health care practitioners (DHCP) can be accomplished by following three basic employee protection schemes (Table I). (45) The most effective method is through the application of engineering and work practice controls. Together, such controls either eliminate or greatly reduce the chances of occupational exposures and injuries.

Where occupational risk remains after application of engineering and work practice controls, personal protective equipment (PPE) should be worn. PPE can and does prevent disease spread in dental environments no matter which mode of spread may be present (Table II).

PPE must be appropriate for the task to be completed and meet the challenges that a given occupational hazard can present. Correct fit increases effectiveness, wearer safety, and wearer comfort. The greater the comfort, the greater the compliance by the health care worker. (1-3)

EYE PROTECTION

There are three types of eye/face protection--safety glasses, face shields and goggles. All are designed to protect in some manner against occupational hazards, such as projectiles, chemicals, dust, heat and biohazards.

Safety glasses are intended to protect the wearer's eyes from hazards, especially against impact and chemicals. Side and top shields offer additional protection against flying objects. Many prescription glasses include adequate impact resistance. Face shields are designed to protect all or part of the wearer's face in addition to the eyes. Face shields best protect against spatter. Goggles are designed to fit the wearer's face immediately surrounding the eyes and form a protective seal. Because of comfort, appearance and ease of use, safety glasses are usually preferred over goggles. (1-3,6)

Tips for wearing protective eyewear include:

* Make sure that all eyewear has adequate impact resistance (e.g., meets American National Standards Institute, ANSI, Standard Z87.1-1989)

* Clean reusable protective eyewear with soap and water

* If visibly soiled, clean and then disinfect

* Thoroughly rinse clean/disinfected eyewear

SURGICAL MASKS

Surgical masks are composed of multiple layers of synthetic (micro fiber) filter materials designed to collect and retain microscopic particles. Masks that filter out [less than or equal to] 95% of small particles that directly contact the mask are sufficiently protective against aerosols and against large droplet spatter. Masks must fit well in order to be protective. Because of fit and composition, most surgical masks used in dentistry are not to be considered as respirators. (1-3,5,6)

Masks come in a variety of shapes and sizes. Some masks are preformed domes, while others are more pliable. Masks are secured to the user by elastic bands, ear loops, or some type of tie. Most masks are form-fitted over the bridge of the nose and cheeks to reduce fogging by warm, expelled air.

In order to have the proper mask for a given application, several different types and sizes of masks must be made available. Change masks between patients, or during patient treatment if the mask becomes wet. Wet masks become less effective. Masks should be removed by touching only the ties, bands or loops.

Masks must be worn in combination with eye protection devices such as goggles or safety glasses with side shields or full-length face shields whenever splashes, spray, spatter or droplets of blood or other potentially infectious materials may be generated and when eye, nose or mouth contamination can be reasonably anticipated.

Tips for wearing masks include:

* Consider filtration efficiency when selecting a mask; choose masks that are rated above 95% efficient; many are rated at close to 99%

* Change masks that become wet or loose-fitting

PROTECTIVE APPAREL

Protective apparel is a type of PPE and should be worn to prevent contamination of street clothing and to protect the skin of DHCP from exposures to blood and body substances. (1-3,6)

Protective apparel comes in two types--reusable and disposable. Ideally, protective clothing should have high necks and long sleeves and have some measure of fluid resistance. Protective apparel should not be worn outside of the facility and should be changed at least daily or when it becomes visibly soiled or when blood or patient body fluids penetrate through.

Tips for protective apparel include:

* Compare the costs of reusable versus disposable gowns

* Compare the cost of professional laundering versus in-house washing

* Select apparel that has high levels of wearer comfort

* Uniforms, pants, and shirts are not considered PPF unless they are intended to protect the DHCP against hazard.

GLOVES

Gloves prevent contamination of health care workers' hands when touching patients or instruments and pieces of equipment contaminated with patient blood and other potentially infectious materials. Gloves also reduce the likelihood that microorganisms present on health care workers' hands can be transmitted to patients during surgery or patient-care procedures. (1-3,6,8)

Medical gloves come in two forms--sterile and nonsterile. Sterile surgeons gloves are to be worn when performing oral surgery procedures. Nonsterile examination gloves are appropriate for all other procedures. Nonmedical, heavy-duty utility gloves are proper for cleaning and disinfection and handling used instruments or chemicals. Non-medical gloves are never to be used during patient care.

A new pair of medical gloves must be worn for each patient. Never wash medical gloves before or during use. Gloves are to be removed after use and hands are then washed immediately to avoid transfer of microorganisms to other patients or the environment. Remove gloves that have become torn, cut or punctured as soon as feasible and wash hands prior to regloving.

Gloves must be appropriate for the hazard present. For example, heat-resistant gloves are to be used when removing sterilized instruments from the autoclave, while puncture=/chemical=resistant are best when handling used instruments prior to cleaning or when performing housekeeping tasks. Appropriate gloves in the correct sizes must be readily available.

Tips for selecting gloves include:

* Match glove composition with the task at hand

* Select glove characteristics of most importance (e.g., fit, cuff length, color, scent, taste and presence of powder)

* Carefully monitor any adverse skin reactions

The Organization for Safety and Asepsis Procedures, OSAP, is dentistry's resource for infection control and safety. OSAP has recently published a book on the CDC Guidelines--From Policy to Practice: OSAP's Guide to the Guidelines. The book is designed to support the efforts of dental practices to better understand the recommendations and to identify effective and efficient methods for compliance. Order information is available at either or 410-571-0003.

Table 1. Employee Protection Schemes *

Engineering Controls     Devices used in the dental setting to reduce
                         exposure to blood and body fluids (e.g.,
                         sharps disposal containers, self-sheathing
                         needles, needle recappers
                         and mechanical instrument washers)

Work Practice Controls   Techniques that reduce the likelihood of
                         exposure by altering the manner in which a
                         task is performed (e.g., no recapping of
                         needles using the two-hand technique,
                         handwashing)

Personal Protective      Specialized clothing or equipment used in oral
  Equipment (PPE)        health care settings include gloves, surgical
                         masks, protective eyewear, face shields, and
                         protective clothing (e.g., gowns and jackets)

* modified from References 4, 5

Table 2. Modes of Disease Spread in Dental Environment*

Direct Contact          Direct contact involves a direct body surface-
                        to-body surface contact and the physical
                        transfer of microorganisms.

                        An example would be touching blood, OPIM or
                        patient tissues with ungloved hands.

Indirect Contact        Indirect contact transmission involves contact
                        of a susceptible host with a contaminated
                        intermediate object, usually inanimate, such as
                        contaminated instruments, hands or gloves.

                        An example would be contacting a used dental
                        instrument or a removable patient appliance.

Droplet Transmission    Droplets are generated from a source patient
                        primarily during coughing, sneezing or talking
                        and during the performance of certain
                        procedures.
                        Transmission occurs when microbes are propelled
                        a short distance through the air into the eyes,
                        nasal mucosa or mouth of a susceptible host.

                        An example would be contact with particles or
                        spatter of patient body fluids; or

Airborne Transmission   Aerosols (evaporated droplets; small particle
                        residue usually five microns or smaller)
                        containing microbes remain suspended in the air
                        for long periods of time. They are dispersed
                        widely by air currents and can be
                        inhaled by a susceptible host.

                        An example is breathing in very small particles
                        coming from patient body fluids.

* modified from References 6, 7

References

(1.) Centers for Disease Control and Prevention. Guideline for infection control in dental health care settings, 2003. MMWR. 2003;52 (RR-17): 1-78.

(2.) Miller, CH and Palenik, CJ. Infection Control and Hazardous Materials Management for the Dental Team, Third Edition, 2004, St. Louis, MO, C.V. Mosby.

(3.) Organization for Safety and Asepsis Procedures. From Policy to Practice: OSAP's Guide to the Guidelines, 2004, Annapolis, MD, OSAP.

(4.) U.S. Occupational Safety and Health Administration. 29 C.F.R. Part 1910.1030. Occupational exposure to bloodborne pathogens; Needlestick and other sharps injuries; Final rule. Federal Register 56:641 75-182, 2001.

(5.) Palenik CJ and Govoni M. Selection and use of masks. Dent Today 23 (February):72, 74-75, 2004.

(6.) Miller CH. Be prepared: a PPE primer, Part I. Dent Prod Report 38 (July):52,54-55, 2004.

(7.) Centers for Disease Control and Prevention. Respiratory hygiene/etiquette in health care settings. Available at: Accessed: September 2004.

(8.) Palenik CJ. Gloves in the dental office: their use and effectiveness. Dent Today. 23 (July):64-67, 2004.

Ginny Jorgensen, CDA, EFDA, EFODA, AAS, has been employed as an orthodontic assistant, general chairside assistant, and a trainer for a large group practice. Currently, she is a full-time, clinical procedures dental assisting instructor at Portland Community College in Portland, Oregon. She is an approved speaker on Bloodborne Pathogens for the National Association of Dental Laboratories (NADL), and is a member of The Dental Assisting National Board (DANB), Infection Control Exam (ICE) test construction committee. Charles John Palenik, MS, PhD, MBA, has held a number of academic and administrative positions at Indiana University School of Dentistry, and currently is Director/Infection Control Research & Services. Dr. Palenik has published hundreds of articles, monographs, books and book chapters, the majority of which involve infection control and human safety and health. In addition, he has provided 110 continuing education courses.