The role of personal protective equipment (PPE) in dentistry
Melissa Loh, Karthikeyan Iyengar and William Loh discuss why PPE is so important in dentistry and what the future of dental care might like look like.
During the height of the COVID-19 climate, elective dental treatment was suspended. The Scottish Dental Clinical Effectiveness Programme (SDCEP) issued guidance on the consistent approach to managing acute dental problems. Whilst also recognising the challenges posed by the COVID-19 pandemic on the provision of dental care in the UK.
However, as the incidence and prevalence in the population of the number of positive cases stabilises, dental treatment will inevitably look to resume.
The World Health Organisation (WHO) describes the spread of coronavirus 2, SARS-CoV-2 by respiratory droplets; this can be through direct contact or via a vector. The ‘simple oral examination’ is classified as an example of an aerosol generating exposure (AGE) by the British Association of Oral & Maxillofacial Surgeons (BAOMS). Hence it is of great importance for a robust and vigilant system to be in place for clinicians to have appropriate protective equipment.
A return to routine dental treatment will make mandatory the theme that good infection control is of paramount importance. The dental team should remain well versed and up to date with the latest COVID-19 PPE guidelines.
The role of personal protective equipment (PPE)
The use of dental rotary instruments such as surgical handpieces and syringes creates an aerosol that can encourage viral transmission. These instruments readily create a spray containing droplets of bodily fluids such as blood, saliva and other debris.
Standard dental surgical masks do not provide complete protection of the mucous membranes from COVID. Understandably, the majority of dental practices do not routinely stock N95 respirators. Nor do they have the appropriate ventilation in the surgery. Hence other precautions, such as PPE, become of great importance.
Public Health England (PHE) issued general guidance on the appropriate PPE required for clinicians working within one metre of patients with possible or confirmed COVID-19. This includes a fluid repellent face mask, apron, nitrile gloves and eye protection (NHS England, 2020).
A more extensive PPE recommendation is advised for any AGPs on probable or confirmed COVID-19 patients.
The World Health Organisation (WHO) recommends PPE includes a filtering face particle 3 (FFP3). It also suggests long-sleeved disposable gowns, and nitrile gloves and eye protection
in the form of goggles or full face visors. As per the standard infection control precautions (SICPs), all gloves and aprons are single use, per patient.
NHS England is aware of the shortages in PPE. Its guidance says it would make regular deliveries during the pandemic to ensure safety of all clinical roles (NHS England, 2020).
The use of an FFP3 mask reduces the amount of aerosol entry by hundred-fold in comparison to the fluid resistant surgical mask. This reduces aerosol entry by just four times in comparison to wearing no mask (Magennis and Coulthard, 2020). FFP3 masks prevent the inhalation of airborne particles and should be:
- Well fitting, covering the nose and mouth
- Should not dangle around the neck of the wearer after or during use
- Do not touch once worn
- Removed outside the clinical area
- Not shared between individuals
- Discarded as clinical waste after use.
Evidence advises the use of FFP2 and N95 respirators, which filter at least 94-95% of airborne particles, if FFP3 masks are unavailable. FFP3 respirators filter at least 99% of airborne particles. Provide appropriate ‘fit testing’ to those intending to wear the respiratory protective equipment to ensure an appropriate seal. Users should repeat a fit test when there is a change in mask model, material or wearer appearance ie facial hair.
Observe appropriate use of the PPE such as education in the ‘donning’ and ‘doffing’ of a surgical gown must be observed, alongside appropriate risk assessment of the clinical setting. Training in the appropriate handling of the surgical gowns as well as handling of the FFP3 mask can be sourced online.
Practices should limit AGP procedures to rooms with the door shut. There should be a restriction in the number of clinical staff wearing the correct PPE present in the room. As per government guidelines, if possible, members of the dental team should strive to maintain social distancing of two metres where possible.
As dentistry moves from the emergency to more elective care in the weeks to come, guidance on the reuse of PPE has been outlined to reserve resources.
No PPE provides complete protection and guidance advises clinicians to appropriately risk assess clinical scenarios (Magennis and Coulthard, 2020). For example, the aerosols generated in a simple oral examination are understandably less than the use of an ultrasonic scaler in dental practice.
Current advice is if it is not feasible for the use of a single FFP3 mask under a full face visor for an entire AGP session, consider donning a fluid repellent surgical mask for the low AGE potential short examinations in order to conserve FFP3 resources (Magennis and Coulthard, 2020).
Due to the potential long durations as to which clinicians will be wearing PPE, guidance has been produced on the effects of caring for the facial skin beneath PPE (NHS, 2020).
General advice includes keeping skin well hydrated by applying moisturising cream half an hour before applying PPE. Seek regular inspection of the underlying skin for areas of redness or soreness. Guidance also advises to keep well hydrated and to take breaks every two hours from wearing the mask (NHS, 2020).
As previously discussed, PPE is not the sole vehicle in reducing the spread of COVID-19 in elective dental care. Hand hygiene also plays an important role in reducing the viral transmission.
We must give an overarching appreciation to restrict the number of patient visits if possible; consider providing longer appointments for the same patient to limit the number of PPEs donned and doffed.
In addition, a consideration for remote or telephone consultations could reduce the number of patients entering the practice. Further, restricting the number of unnecessary staff required in an AGP setting will aid in reducing the number of PPEs. As well as decrease the risk of unnecessary possible COVID-19 contact.
Dental professionals have a duty of care to their patients. They should continue to act in their best interests as per the General Dental Council’s (GDC) standards.
In the future, patients may wear a face mask in the dental surgery whilst in the clinical waiting rooms.
Magennis P and Coulthard P (2020) Re-using FFP3 Masks and risk mitigation as we move from emergency to urgent care. British Association of Oral & Maxillofacial Surgeons
NHS (2020) Helping prevent facial skin damage beneath personal protective equipment
NHS England (2020) Guidance on supply and use of Personal Protective Equipment (PPE)