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

Definitions

  • Level 3: ASTM. International standard related to filtration efficacy, rated between levels 1, 2, or 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 Mask (Level 1 or 3)
    • N95 Mask
    • Respirator Mask
  3. Eye Protection
    • Safety Glasses with Side Shields
    • Safety Goggles
    • Disposable/Reusable Side Shields
    • Loops With Side Shields
    • Face Shield
  4. Gloves
    • Disposable or Treatment Gloves
    • Sterile Gloves
    • Utility Gloves
  5. Protective Cap
    • Reusable Head Covering
    • Disposable Head Bonnet
    • Disposable Shoe Bonnet
  6. Safety Footwear (Shoes)
    • Closed-toe, with no holes across the toes and top of foot
    • Closed-back shoes are not required but strongly encouraged
    • 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

Details and Specifications of PPE

Expanded details of appropriate PPE are provided below. Expanded guidelines on when to use each type of PPE are listed in the upcoming section or may be reviewed within the PPE Decision Matrix. All requirements are subject to change, depending on recommendations from US Centers for Disease Control and Prevention (CDC) and any outstanding communicable disease.

Gowns

  • 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.
  • 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

  • Disposable masks must be ASTM rated or compliant with annual fit testing requirements, if utilizing an N-95 or respirator.
  • Must fully cover nose, mouth, and chin.
  • 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

  • Eye protection includes safety glasses with solid side shields, glasses with disposable or reusable side shields, and loops with solid side shields that are meant to protect the eyes from debris and infectious spatter.
  • Eye protection must fit snuggly over and around eyes, with option to secure 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

  • 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.
  • Must cover forehead, extend below chin, and wrap around both sides of the face.
  • After patient treatment is completed, the shield must be removed and disinfected in the same manner as eye protection.

Gloves: Disposable / Treatment

  • 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 must be removed from holding containers by using clean cotton pliers/forceps or clean, un-gloved hands.

Gloves: Sterile

  • Must be worn in performing and/or assisting in all surgical procedures.
  • All gloves must be changed between patients.
  • All consumable items should be removed and placed in operatory prior to starting treatment. If consumable item is needed after starting treatment, consumable item must be removed from holding containers by using clean cotton pliers or forceps and clean, un-gloved hands.
  • Must be removed before touching drawer handles, chairs, and non-sterile items to avoid contamination of clean supplies.

Gloves: Utility

  • Thick nitrile, puncture resistant, heavy-duty gloves and can be worn when handling or manually cleaning contaminated instruments.
  • Utility gloves are reusable and must be washed, rinsed, and dried based on the manufacturers instructions between uses. 
  • General guidelines for storage includes a system that hangs and/or stores gloves when not in use, in an a designated area.
  • Utility gloves that are peeling, cracking, discolored, torn, punctured, or demonstrating any other signs of deterioration must be disposed of and cannot be used.
  • When disposing, utility gloves must be deposited within an appropriately marked biohazard receptacle. 

Protective Cap

  • Use of a surgical cap/shoe/bonnet is recommended for 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.
    • NOTE: Some programs and/or clinics may require closed-back shoes. Review the appropriate syllabi or clinical manual.
  • 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). OSHA does not regulate or require closed-back shoes and will refer back to organizational discretion.
  • 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.

Guidelines for PPE and Mitigation Measures

Different procedures require different types of PPE, with the most common procedures listed below. 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! Follow PPE requires signs for each clinic, outlining at what point PPE is required. Review the "PPE Decision Matrix" for additional guidance.

Important Notes

  • Faculty, Staff, and Students may upgrade their PPE levels at their discretion. Both the examples below and the PPE Decision 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.
  • 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.
  • If working in a research laboratory, additional PPE guidelines should be observed.

General Non-Clinical Activities

  • Working in office areas, research areas, or attending meetings/classes:
    • No specific PPE required.
    • If symptomatic, do not report to the Adams School of Dentistry.
    • Use the Respiratory/COVID Calculator: bit.ly/asod-covid.
  • Non-clinical areas (e.g., hallways, waiting rooms, atrium):
    • No specific PPE required.
    • If symptomatic, do not report to the Adams School of Dentistry.
    • Use the Respiratory/COVID Calculator: bit.ly/asod-covid.

Clinical Hallways

  • Follow the posted PPE requirements for each clinic. Specific signs indicate where PPE is required.

Clinic-Specific PPE Guidelines

DDS/DH Clinic, Tarrson Hall

  • In clinic operatory without patient, operatory is clean, and is not setup for care.
    • Required: Level 3 Mask
  • Patient present in operatory (before treatment begins):
    • Required: Level 3 mask, gown, and gloves (if using the keyboard).

General Clinical Area Guidelines

These requirements apply to all clinical areas except the Oral Surgery Clinic:

Cleaning and disinfecting treatment areas (before and after patient care) and Instrument Processing:

  • Required: Level 3 mask, gown, safety glasses, and gloves.
  • Optional: Utility gloves.

Exam or consultation (less than 15 minutes, minimal use of air-water syringe):

  • Required: Level 3 mask, gown, safety glasses, and gloves.

Radiographs/Photographs (intraoral or panoramic):

  • Required: Level 3 mask, gown, safety glasses, and gloves.

Procedures using ultrasonic scalers, dental handpieces, air polishing, etc.:

  • Required: Level 3 mask, gown, safety glasses, and gloves.
  • Optional: Fit-tested N95 or higher respirator, face shield.
  • Additional Mitigation: Four-handed dentistry, high evacuation suction, dental dams, and preprocedural mouth rinse.

Endodontic procedures:

  • Required: Level 3 mask, gown, safety glasses, and gloves.
  • Optional: Fit-tested N95 or higher respirator, face shield.
  • Additional Mitigation: Preprocedural mouth rinse.

Surgical and Oral Surgery Clinic PPE Guidelines

Surgical procedures (outside the Oral Surgery Clinic):

  • Required: Level 3 mask, gown, gloves, safety glasses, and head cover.
  • Optional: Fit-tested N95 or higher respirator, face shield, shoe covers.
  • Additional Mitigation: Procedural mouth rinse.

Oral Surgery Clinic (Exam/Consult/Post-op without risk of contamination):

  • Required: Level 3 mask, safety glasses, and gloves.
  • Optional: Gown.

Oral Surgery Clinic (Exam/Consult/Post-op/Surgery with risk of contamination):

  • Required: Level 3 mask, gown, safety glasses, gloves, and head cover.
  • Optional: Fit-tested N95 or higher respirator, face shield, shoe covers.
  • Additional Mitigation: Preprocedural mouth rinse.

Other Activities - PPE Guidelines

Supervising procedural faculty:

  • Required: Level 3 mask, gown, safety glasses, and gloves.
  • Optional: Face shield.

Simulated Clinic and Laboratory Activities (e.g., typodont exercises, lab procedures, student-on-student activities):

  • Required: Level 1 mask, gown or lab coat, safety glasses, and gloves.

Support Services and IT Requests:

  • Required: Level 3 mask, gown, safety glasses, and gloves.

Interpreter:

  • Required: Wear the same level of PPE as the provider being supported.

Protocol for Donning (Putting On) PPE

  1. Perform hand hygiene.
  2. Don clean gown that covers personal clothing and skin.
  3. Optional: Don clean protective cap/bonnet.
  4. Don appropriate mask for clinical activity (e.g., ASTM Level 1, ASTM Level 3, N-95, or Respirator).
    • Fit flexible nose piece over nose bridge and secure to head with ties or elastic straps, fitting snugly.
    • 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 appropriate eye protection (e.g., Glasses, Goggles, Loops, or Face Shield).
  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. Doff 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 appropriate level mask.
    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. Optional: 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:
      • Appropriately labeled receptacle

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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