Page updated 9 October 2006
Personal Protective Clothing
Background
Personal protective equipment (PPE) such as protective clothing and eyewear and disposable gloves are worn as a barrier to prevent the transmission of microorganisms between patients and the dental team. The type of protective clothing required will depend upon the potential risks associated with the planned task. Legally it is the health care worker's responsibility to assess this risk and decide upon the necessary clothing as appropriate. However, the employer must provide suitable PPE that must be freely and readily available for use.
Key points:
The Role of Gloves : -
- To provide a barrier to protect the wearer from contamination with patient's blood or saliva
- To reduce the risk of transmission of microbes from dentist to patient.
- Gloves should be worn for all routine dental treatment and discarded between patients
- Gloves do not prevent sharps injuries but the wiping effect of the glove reduces the risk of contamination.
- Wash hands before donning and after removing gloves
Safe use of gloves in the dental surgery:
- Hands must be washed before donning gloves. Never consider gloves to be an alternative to hand washing
- Gloves protect the operator's hands from contaminated blood and saliva and the patient's microbial flora.
- Never re-use single use disposable gloves.
- Changing your gloves between patients prevents cross infection between patients and contamination of hard surfaces in the surgery. Do not touch patient's notes, pens and computer keyboards, door or drawer handles or your face with gloved hands (see section x on surgery zoning).
- Gloves must only be worn whilst treating the patient and removed at the end of the procedure. Dispose of as hazardous waste. Remember hands are not necessarily clean because gloves have been worn. When removing gloves the patient's microorganisms can be transmitted from the external surface of the glove to the dentist's hands and need to be removed by hand hygiene .
- Change gloves during very long procedures, as u p to 40% of gloves develop tears after prolonged use and may leak . Gloves also become porous during prolonged use due to hydration of the latex. By changing your gloves you can prevent excess sweating and this reduces the risk of dermal infections or inflammation.
Choosing a suitable glove for the task
Disposable gloves are manufactured in a variety of materials and must carry a CE marking denoting acceptable safety levels and performance. Natural rubber latex gloves permit manual dexterity and are impermeable to microbes and are the commonest type of glove used for clinical procedures.
- Use non-sterile gloves for routine dentistry.
- Use sterile surgical gloves for minor oral surgery, periodontal and implant surgery.
- Gloves should be powder-free and have the lowest levels possible of extractable proteins and chemical accelerators (the recommended levels are < 50 m g/g of latex proteins and levels of < 0.1%w/w for residual accelerators).
- Always c hoose a glove that fits you correctly . Gloves that are too small especially if worn for prolonged periods of time will produce muscle fatigue in fingers and hands. If they are excessively tight over the wrists it can exacerbate the symptoms of carpal tunnel syndrome.
- Don't use disposable clinical gloves for scrubbing instruments. To help protect the hands from sharps injuries use heavy duty, lined household gloves for washing instruments and general environmental cleaning. These gloves are reusable, wash whilst on the hands and dry. If excess sweating under the gloves becomes a problem, cotton glove liners can be worn. They need to be checked regularly for small tears, and discarded accordingly.
If you develop an allergy to NRL gloves
Reports of latex sensitivity amongst health care workers (and patients) have risen to 6-18% paralleling the increased clinical use of latex gloves. Sensitivity is particularly common amongst dental staff, and can develop even after successfully wearing NRL gloves for many years. Sensitivity occurs via inhalation of airborne antigens or through damaged skin. The risk of allergic reactions is triggered not only by latex gloves but also by other latex containing devices e.g. rubber dam, syringe and medication vial bungs, prophylaxis cups, orthodontic elastics etc.
Alternative to NRL gloves that have similar physical properties, i.e. do not impair dexterity and are not prone to splitting and are impermeable to blood borne viruses include:
- Nitrile (acylonitrile) /polychloroprene (Neoprene)
- Tactylon (multipolymer synthetic styrene-ethylene-butadine-styrene)
Staff sensitised to natural rubber latex (NRL) gloves must be supplied with appropriate alternatives by the employer.
All staff should be trained to recognise the symptoms both in themselves and patients so that they can avoid the use of latex gloves and devices.
Reactions are classified as:
- Delayed hypersensitivity (type IV) resulting in contact dermatitis, rhinitis, conjunctivitis. This is the most common hypersensitivity reaction to NRL or accelerating agents. Response occurs between 6-48 hours after exposure.
- Immediate hypersensitivity (type I) - asthma, urticaria, laryngeal oedema, anaphylactic shock/collapse. Response occurs 15-30 minutes after exposure.
Creating a low latex or latex free environment
In practices with sensitized individuals all the dental team may need to change to non-latex gloves due to the generation of aeroallergens in the surgery environment. Susceptible clerical staff that do not have direct patient contact can also become sensitised as the latex aerosols travel on air currents permeating office areas and waiting rooms.
Regular changes of ventilation filters; good ventilation, extensive vacuuming and cleaning of surface contaminated with latex allergens will help to reduce environmental contamination with latex proteins. Equipment in the dental emergencies kit should also be free from latex. Seek specialist advice if latex sensitivity is suspected in a member of the dental team. Individuals who have experienced a Type I reaction to NRL should wear a Medic Alert bracelet.
Managing latex allergies in patients
Patients may not always be aware that they have a latex allergy or are at increased risk of developing allergy. Patients who are atopic (predisposition to allergic reactions e.g. hay fever, asthma, eczema) are at increased risk of developing allergy.
- In the medical history include a question on latex allergy (e.g. hypersensitivity reaction following contact with household gloves, blowing up balloons, or food allergies to banana, avocado and kiwi fruit which possess shared antigens with NRL.
- If allergy is known, ensure dental notes are clearly labelled.
- Use latex-free gloves, rubber dams and equipment.
- Remind these patients to inform reception staff when making an appointment and the dentist prior to treatment.
Protective eyewear
The clinical dental team must protect their eyes and those of the patient against splatter, aerosols and foreign bodies such as amalgam fragments.
Goggles:
- Goggles or visors should be worn during all types of dental treatment or when manually cleaning instruments prior to sterilisation.
- Choose goggles or protective glasses with side protection that conform to standard BS EN 166:1988.
- Goggles should be decontaminated according to the manufacturer's instructions e.g. alcohol based surface disinfectant or hypochlorite 1000 ppm available chlorine followed by thorough rinsing in water.
Visors:
- Spectacles do not provide sufficient eye protection, so wear a visor or face shield over spectacles.
- Visors have the added advantage of discouraging touching of the face with contaminated gloved hands.
- Visors are either single use disposable, or if designated re-useable, then follow manufacturer's instructions for cleaning the surface with disinfectant.
- Use disposable visors if treating patients with a contagious respiratory illness (e.g. Flu), as re-useable visors and goggles with elastic straps cannot be readily cleaned.
Surgical face masks
Standard surgical facemasks are resistant to fluids and act as a physical barrier helping to protect the wearer from splashes of blood, saliva and other potentially infectious substances. The main purpose of a mask is to prevent particles (respiratory droplets, skin squames) expelled into the environment by the wearer contaminating the surgical site. Most masks produce a poor facial seal and are not designed to filter the air as it is breathed into the lungs. So do not protect the wearer from aerosol inhalation. Hence, standard surgical facemasks provide no or only partial protection of the wearer from respiratory pathogens such as Mycobacteria tuberculosis or influenza.
- Masks are recommended for all dental procedures
- Masks are single use items. They should be changed after every patient and not reused.
- Try to avoid touching the outer surface of the mask, which may be contaminated.
- Remove the mask by breaking, undoing the straps or lifting over the ears.
- Mask should be disposed of as hazardous clinical waste.
- Clean your hands after removing the mask in order to prevent contamination of your face and the surgery environment.
Respirator type masks
Respirator type masks offer a higher degree of personal respiratory protection compared to a standard facemask. They filter out airborne particles as the air is breathed in through the mask. However, they are not intended to filter out gases.
Such masks are recommended for dental healthcare workers for use whilst treating patients with tuberculosis or other infections that are spread via aerosols e.g. influenza.
In appearance they resemble moulded surgical facemasks. They are made to defined national standards, which differ between the USA and Europe . Only respirators with CE markings that conform to the European standard EN149: 2001 should be worn. The standards define the performance parameters of the respirator mask including filtration efficiency. The European Standard EN149: 2001 FFP2 (94% filtering efficiency) and the approximately equivalent USA type N95 respirator (filters at least 95% of airborne particles) is recommended for use with patients with active tuberculosis and respiratory viral infections.
- When fitted and worn correctly, they seal firmly to the face thus reducing the risk of leakage.
- Beards and stubble interfere with the fit and seal of the respirator.
- Instructions for fitting and the leak tests to be carried out by the wearer differ slightly with each product and are supplied by the manufacturer.
- Avoid touching the outer surface of the respirator mask once it is fitted. Always wash hands after handling the mask.
- Respirators are intended to be single use only. Dispose of as hazardous clinical waste.
Masks with higher filtering efficiency are recommended by the Health Protection Agency (European Standard EN149: 2001 FFP3 [98% filtering efficiency]) for suspected or probable cases of avian flu. ( http://www.hpa.org.uk/infections/topics_az/)
Protective equipment should be removed in the following order :
- First - Gloves (then clean hands)
- Second - Mask (or respirator), or a visor if worn and then mask
- Third - Protective eyewear (goggles)
- Followed by hand hygiene
Gloves are removed first as they will be contaminated on their outer surface with the patient's secretions and this manoeuvre prevents the dental HCW touching and potentially infecting their own skin, eyes or mouth whilst removing the other items of PPE. Removal of gloves immediately after completing treatment also reduces contamination of the surgery environment.
Tunics and uniforms
Tunic/uniforms as a protective barrier
Splatter generated during the use of rotary equipment falls mainly on the operator's face, chest, hands and wrists. To protect these areas of skin from contamination, high-necked tunics /uniforms that cover the chest area, with long sleeves and tight fitting cuffs are advised. Gloves should be worn over the cuff of the sleeve, which protects the wrists from contamination and helps to prevent wetting of the uniform sleeve. If short sleeves uniforms are worn then the wrists and forearms must be cleaned whenever clinical hand hygiene is performed.
However, tunics and uniforms are not usually made of materials that are impermeable to body fluids. Disposable plastic aprons should be made available for staff to wear when contamination of clothing or uniform with blood and body fluids could occur e.g. during minor oral surgery, or periodontal treatment where there is likely to be excessive bleeding or when manually cleaning instruments. Plastic aprons should be discarded after each procedure and between patients.
If there is a high risk of splashing with blood such as during MOS or implant surgery then disposable, impermeable fluid repellent surgical gowns are advised.
Preventing tunics and uniforms becoming a source of infection
Tunics and uniforms become contaminated with microorganisms during clinical treatment. To date no reported dental studies have demonstrated transmission of infection by this route but in hospital wards multi-drug resistant bacteria have been transmitted via contaminated uniforms. Gentleman's ties have been implicated in transmission of MRSA and ties should not be worn when treating patients or should be concealed under the tunic /uniform.
- Therefore, it is recommended that tunics /uniforms are washed and changed daily.
- Protective clothing should not be worn in designated eating and rest areas within the practice. Remove protective clothing when eating and drinking
- Tunics and uniforms and should be removed before leaving the practice.
- When purchasing tunics and other protective clothing choose items that can tolerate washing at the higher temperatures that kill bacteria. Wash protective clothing separately from other clothes using a "hot" washing machine cycle at a setting of 50 o C or above. The heat produced by ironing also contributes to destroying bacteria remaining on clothes.
References
National Institute for Health and Clinical Excellence (NICE) in their infection control guidance
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