Adams School of Dentistry: Infection Control Manual - Chapter 07: Personal Protective Equipment (PPE)

Definitions

• ASTM Level 3: International standard related to filtration efficacy, with Levels 1-3.
• BBP: Blood borne pathogens
• Extraoral: Outside the mouth
• Intraoral: Inside the mouth
• Loops: Specialized eyewear with magnification built in
• Operatory: Room where patient care is provided
• OPIM: Other potentially infectious materials
• PPE: Personal Protective Equipment
• Radiopgrahs: Dental X-rays

Types of Approved PPE

Use of Personal Protective Equipment (PPE) is required both legally and by established policies for all clinical and/or laboratory work. Listed below are the different types of PPE available and appropriate use of each. PPE decision matrix is available in this policy's files and in the "PPE Supplemental Aids & Instructions" section.

1. Gowns
   • Disposable Clinical Gown
   • Reusable Clinical Gown
2. Masks
   • ASTM Certified Level 3 Mask
   • N95 Mask
   • Respirator Mask
3. Eye Protection
   • Safety Glasses with Side Shields
   • Safety Goggles
   • Face Shield
   • Disposable Side Shields
   • Loops With Side Shields
4. Gloves
   • Disposable or Treatment Gloves
   • Sterile Gloves
5. Protective Cap
   • Reusable Head Covering
   • Disposable Head Bonnet
   • (Optional) Disposable Shoe Bonnet
6. Safety Footwear (Shoes)
   • Closed-toe, with no holes across the toes and top of foot
   • Preferably all leather, for ease of cleaning
   • Mesh on sides of shoes are permitted
   • ANY opening on the top or front of shoes are NOT permitted

PPE per Procedure / Area

Different procedures require different types of PPE, with the most common procedures listed below. The easiest method is to assume that if the patient is in an operatory, all PPE should be worn. At no point is ANY PPE allowed to be worn outside of the clinical or instrument processing areas! Consequences of wearing PPE outside of these areas can result in repercussions outlined later in this manual.

Patient is Masked in Operatory

• Gowns must be worn in the operatory
• ASTM Level 3 mask or N95 mask
• Reasoning: No splatter, aerosols, or touching the patient is involved

Patient is UNMASKED in Operatory and Prior to Treatment

• Gowns must be worn in the operatory
• Gloves must be worn while touching the plastic covered keyboard
• Face shield or appropriate eye protection is required
• ASTM Level 3 mask or N95 mask
• Reasoning: It is easier to remember to always wear PPE than specific PPE for different situations. If patient is unmasked, pathogens/aerosols are being released/generated.

Intra-Oral Examinations

• Any procedure that produces debris, spatter, or aerosols, including, but not limited to, oral cancer screening, prophylaxis, operative dental procedures, and surgical dental procedures.
• All PPE is required for provider including gown, mask (surgical, N95, or respirator), face shield, eye protection, gloves, and/or cap/bonnet.
• Patients are required to wear safety glasses.
• Reasoning: Production of aerosols requires full PPE protection for operator.

Radiographs: Intra-Oral & Extra-Oral

• Gown, mask, face shields / eye protection, and gloves are required when exposing intra-oral and extra-oral radiographs.
• Reasoning: Close contact with patient is necessary and is required to wear PPE.

Instrument Processing

• Gown, mask, face shield / eye protection, and gloves are required when working directly with contaminated instruments.
• Areas include Dispensary, Receiving, Decontamination, Wrapping, and Sterilization.
• Reasoning: Close contact with BBP, OPIM, contact with contaminated instruments, and splashes are likely, which requires the use of full PPE.

Approved & Denied Areas for PPE

Scrubs and clinically appropriate footwear is allowed to be worn in all locations. All other items listed under "Types of Approved PPE" are subject to the following restrictions.

Acceptable Locations

• Clinical Areas
• Patient Care Areas
• Dispensary
• Laboratory
• When transporting instrumentation, Tarrson Freight Elevator (located near student clinic dispensaries)
• When transporting instrumentation, Tarrson Clinical Stairwell (located rear of student clinics)

Unacceptable Locations

• Waiting rooms
• Hallways
• Restrooms
• Common Areas
• Koury Hall
• Atrium
• Food Center
• Elevators (except Tarrson Freight Elevator, noted above)
• Stairwells (except Tarrson Clinical Stairwell, noted above)

PPE Specifications

Gowns

• Requirements are subject to change, depending on recommendations from US Centers for Disease Control and Prevention (CDC) and any outstanding communicable disease.
• New gown is used each day and changed if gown becomes wet, visibly soiled, torn, or other method that would reduce efficacy of protection.
• Gowns will be changed between patients if a higher level of care is warranted. Examples include, but not limited to, performing surgical procedures or patient is immunocompromised.
• When temporarily doffing gowns, gown must be hung up in appropriate area (dictated by each clinic). Placing gowns on chairs, cabinets or other surfaces is prohibited.
• At end of clinical day or when changing gowns, gowns must be removed in an aseptic manner and discarded in either marked laundry bins or marked bio-hazard waste receptacles.

Masks

• Requirements are subject to change, depending on recommendations from the CDC and any outstanding communicable disease.
• Disposable masks must be ASTM Level 3 or fit tested N-95 or respirator.
• Must fully cover nose, mouth, and chin.
• Approved masks must be worn during any clinical procedure involving the generation of aerosols or spatter to protect the mouth and nose from airborne infectious agents.
• Applies to provider, assisting personnel, persons providing direct patient care, and any personnel entering the clinical floor.
• Masks are to be changed between patients or when visibly soiled.
• Instructors are to change the disposable mask if aerosols are produced during check steps.

Eye Protection: Loops, Glasses, & Goggles

• Requirements are subject to change, depending on recommendations from CDC and any outstanding communicable disease.
• Eye protection includes safety glasses, glasses with disposable side shields, and loops with solid side shields that are meant to protect the eyes from debris and infectious spatter.
• Eye protection should fit snuggly over and around eyes and secured to head by using earpieces or headband.
• Must be worn whenever there is generation, or probable generation, of spatter and/or aerosols.
• Patients must wear safety glasses, which are shatterproof with solid side shields, whenever in the dental chair.
• Safety glasses may be placed over prescription glasses.
• Patient’s receiving treatment cannot substitute prescription glasses for safety glasses.
• Student-providers are issued 2 pairs of safety glasses upon matriculation and are responsible for using these safety glasses for their patients.
• Protective eyewear used by clinician and patients during treatment must be disinfected after each visit. Disinfection is completed through the following process:
  1. Rinse safety glasses with water to remove debris.
  2. Wipe safety glasses with disinfectant and allow to sit for at least one (1) minute.
  3. Rinse safety glasses again with water.
  4. Dry safety glasses with clean paper towel.
• Loops should be disinfected per the loop manufacturer’s recommendations after each patient encounter that produces spatter and aerosols.
  • Most loop manufacturers will replace side shields that have been lost or broken at no cost.
  • Each provider is responsible for contacting the manufacturer for replacement.

Eye Protection: Face Shield

• Requirements are subject to change, depending on recommendations from CDC and any outstanding communicable disease.
• Face shields protect the entire face from hazards and generally extend from the forehead down, protecting the eyes, nose, and mouth from splatter, but not from aerosols.
• Should cover forehead, extend below chin, and wrap around both sides of the face.
• After patient treatment is completed, the shield should be removed and disinfected in the same manner as eye protection.

Disposable / Treatment Gloves

• Must be worn whenever performing and/or assisting in all intra-oral procedures to protect the hands.
• Must be worn in laboratory settings when there is sufficient probability of exposure to blood and/or OPIM.
• Must be worn when opening and preparing instruments for use, after performing hand hygiene.
• When handling equipment, instrument, and other items which have been contaminated with blood and/or OPIM, prior to being disinfected.
• Wearing disposable treatment gloves outside of the clinical operatory area where residents, students, faculty, or staff is strictly prohibited.
• Environmental Services and individuals specifically disinfecting items outside of the clinical setting are exempt from above restriction.
• No disposable treatment gloves are ever to be washed or disinfected, then re-used for any purpose.
• All gloves must be changed between patients.
• Must be removed before touching drawer handles, chairs, and non-sterile items to avoid contamination of clean supplies.
• All consumable items should be removed from holding containers by using clean cotton pliers/forceps or clean, un-gloved hands.

Sterile Gloves

• Must be worn in performing and/or assisting in all surgical procedures, which includes, but not limited to, access to bone, sub-cutaneous tissues, and so forth.
• All gloves must be changed between patients.
• Must be removed before touching drawer handles, chairs, and non-sterile items to avoid contamination of clean supplies.
• All consumable items should be removed from holding containers by using clean cotton pliers or forceps and clean, un-gloved hands.

Protective Cap

• When gross contamination can be reasonably anticipated, a surgical cap/bonnet must be worn by all surgical personnel and should also be worn by the patient during the surgical procedure (oral surgery and periodontal surgical procedures).
• With respect to extracting teeth, anything other than a simple extraction is considered a surgical procedure and a cap/bonnet must be worn.
• Use of a surgical cap/bonnet is also recommended for other procedures that may produce large amounts of aerosols (i.e., use of high-speed handpiece and ultrasonic scaler).

Safety Footwear (Shoes)

• Safety footwear that are closed-toe, protect the top portion of the foot from dropped instruments, and slip-resistant are required in all clinical, laboratory, and/or research areas.
• Closed-back shoes are strongly recommended but not a requirement set by current OSHA regulations or UNC policies.
• Applies to all providers, assisting personnel, persons providing direct patient care, and all visitors.
• Patients are exempt from this requirement but are encouraged to wear closed-toe shoes.
• General requirements are outlined by OSHA, per 1910.136(a).
• For a complete list of protective shoe requirements, refer to ASTM F2413, subsections I/30, Mt/30, and PR. In order, these sections include impact protection (toes), metatarsal protection, and puncture resistance.

Protocol for Donning (Putting On) PPE

1. Perform hand hygiene.
2. Don clean gown that covers personal clothing and skin.
3. Don clean protective cap/bonnet.
4. Don ASTM Level 3 surgical mask, N-95, or respirator.
   • Fit flexible nose piece over nose bridge and secure to head with ties or elastic straps, fitting snugly.
     • Mask ties should be secured on the crown of the head (top tie) and the base of the neck (bottom tie).
     • Mask loops should be secured around your ears.
     • Once mask is donned, fit check by inhaling, per CDC and the National Institute for Occupational Safety and Health (NIOSH). Mask or respirator should collapse followed by exhaling-check for leakage around face.
   • Using fingertips of both hands, slide down both sides of metal strip to mold to nose.
   • Respirator straps should be place on the crown of the head (top strap) and the base of the neck (bottom strap).
5. Perform a positive and negative user seal each time an N-95 or respirator is donned.
6. Don on face shield and/or appropriate eye protection.
7. Perform hand hygiene.
8. Don clean non-sterile gloves.
   • Ensure comfortable, snug fit on the hand and wrist
     • Should not be too loose or overly tight
     • Loose includes, but not limited to, excess room where glove material bunches up around fingers and/or wrist
     • Overly tight includes, but not limited to, glove material stretching over palm of hand when hand is fully extended
   • Extend gloves over cuff of gown

Protocol for Doffing (Removing) PPE

1. Don treatment/disposable gloves.
   1. Pinch opposite glove at the inside of the wrist and peel off by inverting it.
   2. Roll inverted glove into gloved hand.
   3. Take finger of ungloved hand and slip under the wrist of gloved hand.
   4. Peel off glove by inverting over first glove.
   5. Discard into a biohazard waste container.
2. Perform hand hygiene.
3. Don new, clean set of gloves to remove contaminated items and disinfect operatory.
4. Doff gloves as indicated in Step 1 above and perform hand hygiene.
5. Don new, clean set of gloves again.
6. Doff gown.
   • Touching only the back gown straps, untie and peel away from the neck and shoulders.
   • Turn outside toward inside, rolling into a bundle and discard in appropriate receptacle.
7. Doff eye protection and/or face shields by only touching straps and pulling upwards, away from head.
8. Doff ASTM Level 3 Mask or N95/Respirator.
   1. Touching only the straps or ear loops, remove by pulling over head and away from face.
   2. N95 masks and respirators should be removed by bottom strap first, then remove the top strap.
9. Doff cap or bonnet and store in a disposable bag or place in biohazard receptacle.
10. Doff gloves as indicated in Step 1 above and perform final hand hygiene.

PPE Supplemental Aids & Instructions

If additional aids are necessary for donning or doffing procedure, review the information listed below or contact send an email to ASOD_ClinicalCompliance@unc.edu.

1. PPE Decision Matrix
2. Reducing accidental contamination
   • Always work from clean to dirty by touching only clean body sites or surfaces before touching anything dirty of contaminated.
3. PPE selection
   • Additional guidance on appropriate selection of PPE can be reviewed through the CDC training video.
4. PPE disposal
   • All PPE is required to be disposed of in appropriately labeled receptacles.
   • Failure to utilize the correct receptacle can place others at risk!
   • Appropriately labeled receptacle:
     • 

NOTES:

• If working in a research laboratory, additional PPE guidelines should be observed.
• Commonly used dental equipment known to create aerosols and airborne contamination include ultrasonic scaler, high-speed handpiece, air/water syringe, air polishing, and air abrasion.
• Faculty, Staff, and Students may upgrade their PPE levels at their discretion. This matrix provides the minimally acceptable levels of PPE.
• If clinical faculty or clinical staff direct a student to upgrade their PPE, student must adhere to the upgraded PPE decision.
• Guided questionnaire on Respiratory illnesses, and COVID-19, is available via https://bit.ly/asod-covid.

PPE Training

Appropriate training on the selection, use, and location of PPE is provided either through clinical orientation for clinical faculty and staff, or through relevant course material for students. In certain instances, additional training may need to be provided in the following situations:

1. Workplace changes render prior training obsolete;
2. Availability of specific PPE changes and renders prior training obsolete; and/or
3. Inadequacies are observed in knowledge or use of assigned PPE that indicate the student, faculty, or staff has not retained an understanding of PPE training.

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