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A safe dental environment for both the patient and the practitioner is a standard of care. Strict protocols should be followed for disinfecting, sterilizing, and maintaining the dental office, as recommended by the American Dental Association (ADA) and the Centers for Disease Control and Prevention (CDC). In addition to following protocols for the operatory, treatment rooms, and sterilization area, dental personnel are also required to wear personal protective equipment (PPE). According to CDC guidelines for infection control in the dental healthcare setting, PPE should consist of special coverings designed to protect dental personnel from exposure to or contact with infectious agents. Specific PPE items include face masks, gloves, protective eyewear, face shields, and protective clothing (eg, reusable or disposable gowns, jackets, and laboratory coats).1
ASTM International, formerly known as American Society for Testing and Materials, is an international standards organization that develops and publishes voluntary consensus technical standards for a wide range of materials, products, systems, and services. Recognized by the US Food and Drug Administration (FDA), ASTM International has long been one of the largest standards organizations for the testing of face masks.2ASTM Standard F2100-11 is the specification for performance of the materials in medical face masks. This standard covers the testing and construction requirements used in the masks as well as the masks' medical performance. Masks can vary in protection level from serving as a simple barrier to providing stronger protection during procedures where heavy amounts of fluids may be involved; beyond the basic minimum protection masks, there are three stronger levels of protection (Table 1).
In regard to performance, the FDA recommends that masks be considered according to four criteria: fluid resistance, filtration, differential pressure, and flammability. These are defining parameters for surgical masks according to the ASTM. Fluid resistance is a mask's resistance to penetration by synthetic blood under pressure; hence, the mm Hg denotation (Table 1). Higher resistance levels offer more protection. Bacterial filtration efficiency (BFE) is the percentage of particles that are filtered out of a pore size of 1 to 5 microns (µm). Submicron particulate bacterial filtration efficiency (PFE) is the percentage of particles filtered out at an even smaller diameter of 0.1 to 1 µm. Pressure drop measures delta P, or differential pressure, across the mask, or resistance to air flow (mm H2O/cm2). The greater the resistance to airflow, the better and higher the ASTM designation, but breathability through the mask may be affected. Finally, flame spread measures the spread of flame through the material if it catches fire. These parameters are all indicated on the package of masks, allowing one to easily determine the protection level of the mask.
Masks need to fit the clinician's face. Besides being available at different filtration levels, masks come in a variety of sizes. When choosing a mask, the potential zone of spatter should be considered. A mask should fit up to just below the protective eyewear to cover more of the face. Most masks are manufactured with both a nose and chin adjustment to securely cover and close off as much of the face as possible. Finally, masks are one-time use and need to be replaced if wet or spattered with blood.
Gloves have a similar set of specifications.3As with face masks, the ASTM has standards for both surgical and examination gloves. The standard of assessment for medical gloves may be found under ASTM D7103 - 06(2013).4Performance of gloves is evaluated on a variety of parameters, including tensile strength, puncture resistance, and elongation percentage. Gloves are either natural rubber latex or synthetic, which includes nitrile, neoprene (polychloroprene), thermoplastic elastomers (polyethylene and polyurethane), and solvent-dipped processed types (polyvinyl chloride, polyvinyl chloride copolymer, and block copolymer).5-9 Natural rubber latex gloves are very elastic, but due to contact sensitivity or overt allergies of either the practitioner or the patient, some clinicians have moved to nitrile gloves.
Historically, gloves were either powdered or powder free; clinicians were free to choose which type of gloves they preferred. However, on December 19, 2016, the FDA published a final rule banning powdered gloves.10 The ban was based on a substantial risk of illness or injury from exposure to powdered gloves. But, according to the FDA, the guidance document was not updated to reflect the ban.10The key point in choosing gloves is a proper fit. Gloves serve as a necessary protective barrier but potentially affect tactile sensitivity. The author recalls a time when gloves were not required, except possibly in cases of venereal diseases or overt herpes lesions. Procedures such as scaling and root planing were performed; then, after a thorough handwashing, clinicians went out to enjoy lunch.
The CDC and Occupational Safety and Health Administration (OSHA) have since set guidelines that list protocols for gloves in a dental setting.7,11 Medical gloves should be worn if there is any potential to encounter blood, saliva, or potentially infectious tissue. It is also a standard of care to remove gloves when the chain of sterility is broken in a procedure, to discard gloves if they have a tear or puncture, and to use each pair of gloves just one time.
Although most dental professionals are aware of the need for protective gloves, garments, and masks, how much focus is on eyewear? Protective eyewear has specific requirements, but it is usually neglected or minimized.12,13The standards for eye protection come from OSHA.12,13 The CDC requires protective eyewear for both the patient and practitioner. The Guidelines for Infection Control in Dental Health-Care Settings 200314 from the CDC is very specific about the type of protective eyewear necessary. According to the guidelines, protective eyewear with solid side shields or a face shield should be worn by dental healthcare personnel during procedures and patient-care activities likely to generate splashes or sprays of blood or body fluids. Protective eyewear for patients shields their eyes from spatter or debris generated during dental procedures.15
Eye injuries are preventable, yet the compliance rate for wearing correct protective eyewear is low. In one study, compliance was reported at 60.3% for dentists and 34.1% for hygienists.16 Another study cited that of dental practitioners were more compliant, at a rate of 87% routinely wearing eye protection. This same study indicated 96% of dental hygienists wore eye protection for the majority of their patient work.17Regardless of the exact figures, if a practitioner is not wearing glasses, are the patients likely to wear them?
What about ocular injuries? According to a study, 48% of general practice dentists have experienced ocular trauma or injuries while performing dental procedures. Of these, 75% were not wearing protective eyewear at the time of the injury.17,18The good news is that in the same study, dental assistants and dental hygienists did not experience such a high rate of trauma due to their compliance rate of wearing eye protection.17,18
What are the risks to eyes? Due to the nature of dental equipment, spray from high-speed handpieces, air polishers, or ultrasonic scalers may cause blood, saliva, or other contaminated liquids to spatter and aerosolize.19-21Additionally, bacteria may become airborne. The contaminated aerosols may float in the air for a time and may contaminate both clinician and patient.22Prophylactic polishing pastes may spatter, as well as acid from etchants in both general practices and orthodontic offices. Chemical disinfectants and cleaning solutions may also splash into the eyes during routine infection control procedures in the office. Finally, eyes need to be protected from lasers, ultraviolet radiation, and curing lights.
Due to a constant risk of mechanical or bacterial contamination to the eyes of personnel in the dental office, protection is necessary. There are two types of injuries to eyes: infection and trauma.23Infection may occur after trauma or on its own. Several types of trauma to the eye can occur: corneal abrasions, a torn iris, lacerations, and chemical injuries. All are painful, and some require surgery to repair. Infections can include bacterial conjunctivitis; viral keratitis involving a herpes simplex infection; or hepatitis B, hepatitis C, or HIV.23
Eye injuries are involved in 10% of all injuries in a dental office.23 The main causes are the high-speed preparations and the ensuing shrapnel that may be let loose from the tooth. These injuries may also occur in oral surgery and orthodontic settings. Injuries may begin with a foreign body lodging in the conjunctival sac, but the object may enter the cornea and cause more harm.24
Injuries to the Eyes of Patients
One of the most extensively reported eye accidents to occur in a dental office was not with a clinician. A woman named Jennifer Kushwara Morrone had an incident occur during an endodontic procedure. Her clinician was passing a syringe to the dental assistant, and rather than going across her chest, he went over her face, and the needle dropped into her eye, puncturing the eye with bacteria. Unfortunately, she was not wearing any eye protection at the time. She lost her vision in her right eye after multiple biopsies and removal of her lens due to retinal detachment.25,26 Jenn was never offered glasses to protect her eyes during the procedure. Jenn is now an advocate for educating patients about the need to wear protective eyewear, just like clinicians. Jenn has a Facebook hashtag movement (#JennsVisionSunglassSelfie), a Facebook page (www.Facebook.com/JennsVision), and a YouTube video (www.youtube.com/watch?v=7r0jVgHx2do).18
Another eye-related incident occurred when water was sprayed into a patient's eye during treatment. Amoeba were found in corneal samples, and the patient's visual acuity decreased after the event.27
Features of Protective Eyewear
Wearing protective eyewear, for both the clinician and the patient, is imperative. Care needs to be given as to the type of glasses worn and their functions. Normal reading glasses are not considered proper protection. Clinicians should wear protective eyewear that has nonremovable side shields that will protect the eyes from all sides during a procedure with the potential of aerosol or spray of body fluids.12 Care must be given to dental loupes to ensure they have the same side eye protection. Patients need the same protection. Several manufacturers sell appropriate protective eyewear for dental clinicians as well as patients. Some of these eyewear types are able to be disinfected, and others are single use. Single-use eyewear is a good choice to offer to patients. Key features of protective eyewear12:
• wraparound eye protection
• nonremovable side shields
• impact-resistant plastic
The ADA offers assistance for clinicians on eye safety as well as protocol to follow if there is an injury at the office.28 Dental professionals routinely follow many standards of care for infection control. The use of personal protective equipment, such as face masks and gloves, has become common. It is time to consider more thorough incorporation of protective eyewear into the mix, including for patients. Wearing properly featured and fitting safety glasses will protect both the clinician and patient from preventable eye injuries.
about the author
Sheri B. Doniger, DDS
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