Infection Control Guidelines for PPE

Dental providers and dental schools are currently facing a number of new challenges due to the COVID-19 pandemic. As COVID-19 can be transmitted asymptomatically and pre-symptomatically, we must act as if everyone is infectious. COVID-19 is primarily transmitted through aerosols generated by coughing, sneezing or talking between people who are within 6 feet (2 meters) of each other. While surface transmission of COVID-19 is less common, the virus that causes COVID-19 has the potential to survive for hours or days on different surfaces including dental equipment and clothing.

These characteristics of COVID-19, along with the close personal contact, and aerosol generating dental and surgical instruments involved in dental care, place dental health professionals at a high risk for infection. Aerosolized saliva and droplets generated during dental procedures performed on a COVID-19 infected patient may contain heavy viral loads, even if a patient is asymptomatic. 

The best method to protect patients and members of the dental community from infection is to assume that all patients carry the COVID-19 causing virus. Hence, advanced personal protection equipment (PPE) and PPE disinfection procedures must be used by the students, staff and faculty involved in patient care. Strict protocols for disinfection of the clinical cubicles, cabinets, and surfaces must be followed after the completion of dental care for each patient.

In addition to following all existing standard precautions and infection control procedures:

  1. All staff, students, and faculty must always wear a face mask or cloth covering while inside the school.
  2. Patients must supply their own masks and wear them when they enter the dental school.
    1. Patients will not enter the building until their appointment begins.
  3. Everyone entering the dental school will be screened for fever.
  4. Students, faculty and staff involved in clinical and preclinical activities will be provided with a launderable surgical gown.
    1. Current student white lab coats ARE NOT to be worn and must be removed from the school.
  5. Students, faculty and staff involved in patient care will be issued face shields.
  6. When engaging in patient care, students, faculty and staff will use procedure appropriate PPE and face coverings.
    1. Non-aerosol generating procedures: Surgical mask and eye protection (goggles/glasses with side shields). Face shields may be worn. N95/KN95 masks ARE NOT necessary for these procedures.
    2. Aerosol generating procedures: N95/KN95 masks with an overlay of a surgical mask, eye protection and face shield
    1. Washing hands with soap and water or applying disinfectant cleanser after touching a potentially contaminated surface is necessary for preventing infection with COVID-19.
    2. If you must touch your face covering, mask, eye protection, face shield or another contaminated or potentially contaminated surface, perform hand hygiene immediately before and after.
    3. It is important that a habit of not touching the face, eyes or nostrils be adhered to.
    4. After removing surgical or N95/KN95 masks, resume wearing personal mask or face covering.

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    Personal Protective Equipment (PPE) for the Dental Healthcare Provider

    PPE items include:

    • Gloves
    • Launderable Gowns
    • Face shields
    • Masks (Surgical, N95 or KN95)
    • Hair bonnet
    • Eye protection (goggles, safety glasses with side shields)

    Dental Healthcare Providers using PPE must observe the following precautions:

    • Wash hands immediately after removal of gloves or other personal protective equipment.
    • Remove protective equipment before leaving the work area or after a PPE/ garment becomes visibly contaminated.
    • Place used protective equipment in appropriately designated areas or containers when being stored, laundered, decontaminated, or discarded.
    • Gloves must be worn during contact with saliva, blood or other potentially infectious bodily fluids and when handling or touching contaminated items or surfaces. Replace gloves if torn, punctured, contaminated, or if their ability to function as a barrier is compromised.
    • Following any contact of body areas with blood or any other infectious materials, you must wash your hands and any other exposed skin with soap and water as soon as possible.
    • Exposed mucous membranes such as eyes must be flushed with water at dedicated eye wash stations.
    • Wear appropriate face and eye protection (solid face shields/chin-length face shield) when splashes, sprays, splatters, or droplets of blood or other potentially infectious materials are generated.
    • If a garment is penetrated by blood and other potentially infectious materials, the garment(s) must be removed immediately or as soon as feasible.

How to Put On (Don) PPE

More than one donning method may be acceptable. Training and practice are critical.

1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training).
2. Perform hand hygiene using soap and water or hand sanitizer.
3. Put on isolation gown. Tie all the ties on the gown. Assistance may be needed by other healthcare personnel.
4. Put on procedure appropriate facemask (surgical mask or N95/KN95 with surgical mask)
     a. Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears.
     b. If using N95/KN95 masks:
          i. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients.
          ii. Respirator: Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator.
5. Put on face shield or goggles. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common.
6. Perform hand hygiene before putting on gloves. Gloves should cover the cuff (wrist) of gown.
7. Healthcare personnel may now enter patient area.

How to Take Off (Doff) PPE

1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak).
2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach.
3. Healthcare personnel may now exit patient area.
4. Perform hand hygiene.
5. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles.
6. Remove and discard respirator (or facemask if used instead of respirator). Do not touch the front of the respirator or facemask.
        a. Facemask: Carefully untie (or unhook from the ears) and pull away from face without touching the front.
        b. N95/KN95 masks: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator. See above for UV disinfection and reuse.
7. Perform hand hygiene after removing the respirator/facemask and before putting it on again.