Understanding what really protects us in dentistry—it isn’t just our PPE

With editorial assistance from Shari Chase

Our PPE is not the only thing to protect us in dentistry. There are many other defenses and precautions that keep us safe and limit the spread of infection.

The COVID-19 pandemic has brought to light multiple perspectives on the use of personal protective equipment (PPE) in dentistry. Some practitioners believe that we have good enough PPE in dentistry and should be allowed to continue working throughout the pandemic, while others are afraid to return to their workplaces because they fear for their own and their patients’ health.

What neither of these groups seems to recognize is that PPE is the last control we have to protect ourselves against infectious disease. Rather than relying on the false sense of security it provides, we should constantly be taking precautions and following protocols that promote safe environments in our dental practices.¹ We have to review and reinforce proper safety protocols so that our PPE is only there to protect us if, in a rare instance, all of our other lines of defense against infection have failed.

The last defense

The term PPE refers to protective clothing, including gloves, face shields, eyewear, facemasks, and/or other equipment designed to protect the wearer from injury or the spread of infection.² Most commonly used in health-care settings, PPE acts as a barrier between infectious materials and your skin, mouth, nose, or eyes. It is essential, however, that PPE is used with other infection control practices such as hand washing, using alcohol-based hand sanitizers, and the consistent enforcement of infection prevention practices.

The chain of infection

In addition to following safety protocols, it is worthwhile to remember the difference between bacteria and viruses when thinking about the chain of infection. Although both are microbes with the potential to cause infections, they behave in very different ways. Viruses, such as the novel coronavirus, are smaller than even the smallest of bacteria, reproduce quickly by using host cells to make new viruses, and are much more likely to cause disease.³ In general, viral infections are also more challenging to treat due to their tiny size and as they reproduce inside of cells.

The chain of infection refers to the series of events that allow pathogens to cause infection in a person.⁴ This chain begins with an infectious agent, or pathogen, finding a “portal of exit.” Upon finding this exit, the pathogen can leave its reservoir and travel through space. As it travels, whether by direct or indirect contact, it searches for a “portal of entry” and enters a new, susceptible host.⁵ This may sound complicated, but it can happen within an instant. The easiest way to stop pathogens from spreading is to interrupt the chain through understanding the portals of exit and entry and modes of viral transmission and adopt the appropriate infection control measures.⁶

Some ways to break the cycle of infection include eliminating the agent at its source of transmission, protecting portals of entry, and increasing the host’s defense so that there are fewer new and susceptible hosts.⁶ We examine how dental professionals can increase their defenses against infection in the workplace.

First defense

The fight against infection begins with the implementation of the hierarchy of controls as follows:⁷

1.  Eliminate workplace conditions or contagious individuals that negatively impact well-being.

2. Replace or substitute unsafe/unhealthy working practices with policies that improve the culture of safety and health in the workplace

3. Redesign or rearrange the workplace to promote safer practices.

4. Provide safety and health resources for employees.

5. Encourage personal change, so that individuals will do their part to keep the office safe.

Following these control guidelines is the first step to bolstering your practice’s defenses against the spread of viral infections. The second step is to recognize and understand the unique dangers present in a dental office. The face-to-face nature of dentistry, in combination with the exposure to saliva, blood, and other bodily fluids, makes it very easy to transmit infections.⁸ As a result, dental professionals must adopt infection control measures to limit the airborne spread (often through aerosols), the contact spread, and the contamination of surfaces. Some protocols to protect against these transmissions of infection include the following.

Screening patients prior to their appointments⁹

The best way to break the chain of infection is to prevent the introduction of the pathogens in the first place. Sick patients and employees should not enter the building. Screening patients, by asking basic triage questions before their appointments is the best way to determine if they are healthy enough to continue with their scheduled procedures. This does not mean only during a pandemic but forever!

Staying home if you are sick¹⁰

Any employee that does not feel well should stay home. If you are ill, you are a potential hazard in the workplace and better serve everyone by isolating yourself and getting better.

Oral professionals should properly wash¹² or disinfect their hands before the patient examination, before starting any procedures, after touching the patient, and after touching any of the surrounding medical equipment.

Opting for procedures that create fewer aerosols, if possible

The aerosols and spatter created in many dental procedures can stay airborne for long periods, thereby creating a risk for the transmission of infection via the respiratory passages.¹³ Certain procedures, such as those that use ultrasonic scalers, air polishing, air abrasion, and air-water syringes, create more aerosols than others. During a pandemic or outbreak, it is wise to opt for methods that will create fewer airborne droplets. When this is not possible, devices such as a high-volume evacuator¹⁴ are imperative to limit the spread of these contaminated droplets.

Implementing preoperational mouth rinses before dental procedures⁸

Preoperational antimicrobial mouth rinse may reduce the number of oral microbes present in the patient’s mouth. In procedures known to create more aerosols, a mouth rinse can limit exposure to pathogens.

Utilizing rubber dams

A rubber dam is a thin, six-inch, square sheet of latex used to isolate one or more teeth from the rest of the mouth during dental procedures.¹⁵ This isolation can reduce the likelihood of spreading bacteria and saliva from the patient’s mouth.

Regular cleaning of your office is always important and should follow the directions present on the cleaning and disinfectant supplies. When applicable, implement extra measures such as air cleaning systems to reduce the size of any bioaerosols that might be present in the air.¹⁶

Reviewing the proper use of PPE

As stated earlier, PPE is the final defense, but it only works if used properly. Worn whenever there is potential for contact with spray or spatter,¹⁷ there must also be strict adherence to the guidelines for putting on, taking off, and disposing of the materials.

Preventative care is the best approach

Many may tell you that their protocols are good enough because no one has gotten sick. However, that attitude is not good enough. We cannot wait for someone to get sick before we decide to follow precautionary principles.¹⁸ Yes, it will require effort on our parts, but if COVID-19 has taught us anything, it is that that effort is vital for the continued health of our communities.

Even after all of this is over and we go back to “business as usual,” dental professionals need to reevaluate their protocols and make sure that we are doing everything possible to protect workers and patients. Dental offices have characteristics that warrant additional infection control protocols,⁹ and we must be aware of how our practices have the potential to aerosolize infectious aerosols and be a vector for disease.

Although COVID-19 may seem like a complete aberration, there have been other viruses throughout history¹⁹ that have changed the way we live. Nevertheless, we have survived and learned how to protect ourselves better, but with that said, all of the knowledge in the world is useless if we don’t put it into practice. What really protects us in dentistry is understanding the chain of infection and working tirelessly to break it at every step of the way. COVID-19 is not the last threat to our health, rather a reminder of what we should regularly be doing to protect ourselves and keep our patients healthy.

References

1. World Health Organization. Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19). February 27, 2020. Accessed April 19, 2020. https://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-eng.pdf

2. Personal protective equipment for infection control. US Food and Drug Administration. Updated February 10, 2020. Accessed April 19, 2020.  https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/personal-protective-equipment-infection-control

3. Bacteria and viral infections. WebMD. Accessed April 19, 2020. https://www.webmd.com/a-to-z-guides/bacterial-and-viral-infections#1

4. Chain of infection. The Royal College of Nursing. Accessed April 19, 2020. https://rcni.com/hosted-content/rcn/first-steps/chain-of-infection

5. Association for Professionals in Infection Control and Epidemiology. Break the chain of infection [infographic]. Infection Control and You. Accessed April 19, 2020. https://professionals.site.apic.org/protect-your-patients/break-the-chain-of-infection/

6. Section 10: Chain of infection. Lesson 1: Introduction to Epidemiology. Centers for Disease Control and Prevention. Principles of Epidemiology in Public Health Practice. 3rd ed. October 2006. Updated May 2012. Accessed April 19, 2020. https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section10.html

7. Tools: Let’s get started. Total worker health. Centers for Disease Control and Prevention. Accessed April 19, 2020. https://www.cdc.gov/niosh/twh/letsgetstarted.html

8. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci. 2020 Mar 3;12(1):9. doi:10.1038/s41368-020-0075-9

9. Interim infection prevention and control guidance for dental settings during the COVID-19 response. Centers for Disease Control and Prevention. Accessed April 19, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html

10. Stay home if you’re sick [flier]. Centers for Disease Control and Prevention. Accessed April 19, 2020. https://www.cdc.gov/nonpharmaceutical-interventions/pdf/stay-home-youre-sick-employers-item4.pdf

11. What is hand hygiene? Infection prevention and control in dental settings. Centers for Disease Control and Prevention. Reviewed March 1, 2016. Accessed April 19, 2020. https://www.cdc.gov/oralhealth/infectioncontrol/faqs/hand-hygiene.html

12. Dryer LN. Clean hands: Protocol for maintaining proper hand hygiene. Published March 1, 2010. Accessed April 19, 2020. https://www.rdhmag.com/infection-control/disinfection/article/16407793/clean-hands

13. Harrel SK, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. J Am Dent Assoc. 2004;135(4):429‐437. doi:10.14219/jada.archive.2004.0207

14. Emmons L, Wu Cheri, Shutter T. High-volume evacuation: Aerosols—it’s what you can’t see that can hurt you. RDH magazine. Published July 1, 2017. Accessed April 19, 2020. https://www.rdhmag.com/patient-care/article/16409779/highvolume-evacuation-aerosolsits-what-you-cant-see-that-can-hurt-you

15. Violante S. Dammed if you do, dammed if you don’t. RDH magazine. Published March 1, 2018. Accessed April 19, 2020. https://www.rdhmag.com/patient-care/article/16408220/dammed-if-you-do-dammed-if-you-dont

16. Hallier C, Williams DW, Potts AJ, Lewis MA. A pilot study of bioaerosol reduction using an air cleaning system during dental procedures. Br Dent J. 2010;209(8):E14. doi:10.1038/sj.bdj.2010.975

17. National Center for Chronic Disease Prevention and Health Promotion: Centers for Disease Control and Prevention. Summary of infection prevention practices in dental settings: Basic expectations for safe care. Accessed April 19, 2020. https://www.cdc.gov/oralhealth/pdfs_and_other_files/BESC3-PPE-508.pdf

18. Application of hazard control principles, including the precautionary principle to infection agents. Ontario Health Care Health and Safety Committee. Published October 2011. Accessed April 19, 2020.

18. “Application of Hazard Control Principles, including the Precautionary Principle to Infectious Agents”. Oct. 2011. https://terraform-20180423174453746800000001.s3.amazonaws.com/attachments/cjiisgnj00040fxj7ys592r7y-approved-hazard-control-principles-pp-to-infectious-agents-eng-gn.pdf

19. Harding A, Lanese N. The 12 deadliest viruses on Earth. LiveScience. Published March 4, 2020. Accessed April 19, 2020. https://www.livescience.com/56598-deadliest-viruses-on-earth.html

Michelle Strange, MSDH, RDH, brings 19 years of experience in dentistry to her roles as adjunct clinical faculty member at Trident Technical College, clinical educator for TePe Oral Health Care, director of education for O2 Nose Filters, and host of the “A Tale of Two Hygienists” podcast. In 2019, she started a company with Dr. Tony Stefanou called TriviaDent to test your dental knowledge, network, and win prizes. You can reach out to Michelle via her podcast ataleoftwohygienists.com.