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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 132-135

Personal protective equipment: A solution to occupational hazard or an occupational hazard itself?


Department of Conservative Dentistry and Endodontics, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India

Date of Submission26-Oct-2020
Date of Acceptance22-Feb-2021
Date of Web Publication16-Jul-2021

Correspondence Address:
Neha Verma
Department of Conservative Dentistry and Endodontics, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_152_20

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  Abstract 


Personal protective equipment (PPE) has become an important and much talked about subject during the current coronavirus pandemic. Since the dental profession predominantly involves exposure of the dentist to various body fluids such as saliva and blood., the use of PPE is imperative for infection control in dental practice. However, even though protection is successfully achieved by PPE, such high level of protection is likely to entail additional workloads and occupational hazards on healthcare professionals including dentists. The present review aims to throw light on the occupational hazards that can occur and some tips to alleviate the discomfort following the use of PPE. These methods are relatively simple to follow while maintaining normal healthcare routine.

Keywords: COVID-19, dentistry, occupational hazard, personal protective equipment


How to cite this article:
Verma N, Singla MG. Personal protective equipment: A solution to occupational hazard or an occupational hazard itself?. J Dent Res Rev 2021;8:132-5

How to cite this URL:
Verma N, Singla MG. Personal protective equipment: A solution to occupational hazard or an occupational hazard itself?. J Dent Res Rev [serial online] 2021 [cited 2021 Sep 27];8:132-5. Available from: https://www.jdrr.org/text.asp?2021/8/2/132/321531




  Introduction Top


Occupational hazard refers to a risk or danger as a consequence of the nature or working condition of a particular job.[1] Dentists while carrying out their professional work are exposed to various occupational hazards; one of them is getting infected from the patient.[2] These days the world is suffering from novel coronavirus (2019-nCoV), the seventh member of the family "coronaviruses" which infects humans.[3] Dentists also are at tremendous risk of acquiring this infection from their patient.

COVID-19 transmission in dental settings occurs through four major routes:

  1. Direct exposure to respiratory secretions containing droplets, saliva, blood, or other patient materials
  2. Direct inhalation of suspended airborne viruses
  3. Indirect contact with contaminated surfaces and/or instruments
  4. Mucosal (nasal, oral, and conjunctival) contact with infection-containing droplets and aerosols that are propelled by coughing and talking without a mask.[4]


Due to the specificity of dental procedures which include dealing with the head-and-neck region, especially performing aerosol-generating procedures in the oral cavity, the risk of COVID-19 transmissions in dental professionals is very high.[5] In spite of these vulnerabilities of COVID-19 transmissions which expose one to endanger, the dental professionals cannot refrain from providing care and serving community.[4],[5] Thus, it is of utmost importance to incorporate maximum precautionary measures including donning personal protective equipment (PPE) in order to prevent transmission and spread of infection among dental professionals. PPE includes surgical scrub suit, eye protection, different types of masks, fluid-resistant gown, disposable apron, gloves, head cap, face shield, shoe cover, etc., which is designed to protect the skin and the mucous membranes of the eyes, nose, and mouth of dental healthcare personnel from exposure to contaminated blood, saliva, aerosols, or other potentially infectious material.[6]

However, dental professionals are facing many problems while using these PPE for example wearing eye protection, face shields, and face mask simultaneously results in fogging and glaring which ultimately leads to restricted vision. Long-term utilization of N95 mask results in hypoxemia and hypercapnia eventually causes headache. Scar on the nasal bridge and cheeks may be caused by the excessive pressure of tying mask tightly and squeezing the metal clip hard. Furthermore, wearing N95 mask along with heavy respirator can further cause difficulty in communication with the patient. Wearing multiple layers of PPE results in body's inability to cool down adequately known as heat stress which causes dehydration, breathing difficulty, profuse sweating, dizziness, dry mouth, dark urine, and exhaustion. Apart from these other problems are skin irritation, runny/blocked/stuffy nose, dry/itchy/watery eyes, sneeze, cough, etc.[7],[8],[9]

Various measures can be taken by the dental professionals to alleviate the discomfort while wearing PPE which can be as follow:

  • Prefer ventilated environment for dental procedures
  • Apply moisturizer at least 30 min before donning PPE
  • PPE should be of proper fitting
  • Pay attention to the material of clothing worn inside. Select breathable, light-colored, moisture-wicking fabrics for surgical scrub suits, gowns, and surgical caps or take it one step further to try cooling vests which can be fitted with ice pack
  • As the surgical cap can retain heat. One can leave his/her hair slightly damp under the cap to reduce the heat or choose a slightly larger size to allow heat to escape
  • Face masks with ties should be preferred. Buttons on surgical caps can reduce strain on ears from mask ear loops. Ear savers are another great product to reduce the same
  • To mitigate pressure for minimizing the risk of pressure damage to the skin, barrier dressing tapes and liquid barrier film (which is easy to apply, dries only in 30 seconds, and forms an invisible barrier for up to 72 hours even with normal washing) can be used under masks and goggles
  • Sign/body languages or notepad can be helpful in avoiding communication difficulties with patients while wearing multiple layers of PPE
  • Try not to wear PPE, especially FFP3 masks for more than two hours at a time
  • Schedule in-between breaks
  • To avoid eye problems, eyes should be washed with cool water. Over-the-counter eye drops can also be helpful in soothing dry/itchy/watery/irritated eyes
  • Drink enough fluids preferably water during the parts of the day when most convenient to do so
  • Avoid energy/sports/caffeinated/aerated/sugary/alcoholic drinks which claim to support or enhance hydration, but can have negative impact on the kidneys owing to their very low pH, high titratable acidity levels and high sodium content which can result in dehydration on excessive intake
  • Fruit-infused water, water with a slice of lemon, iced herbal teas, and yogurt offer a refreshing alternative
  • Try a drop of peppermint oil, cooling towels, and cooling gel packs from the freezer. When these placed on pulse points such as the neck, temples, and wrists can reduce body heat quickly and create a cooling sensation during a break, setting dental professional up for the next patient with a cooler body temperature
  • Practice various breathing exercises for increasing the lungs capacity.[9],[10],[11],[12]



  Advisory to the Patients Top


It is important for patients visiting the dental office to follow all necessary precautions for controlling COVID-19 spread. Wearing of masks, hand hygiene, and social distancing while in the waiting area should be strictly practiced in the dental office. Scheduling a prior appointment over telephone or other Internet-based communication system is recommended before attending dental office. Patients should reveal about any symptoms resembling a cold, flu, or even stomach/digestive issues as well as about any recent travel.[13] For health protection, it is advisable for patients to wait in their vehicle, if possible, or at a place nearby to the dental clinic, and the dental assistant/receptionist should preferably communicate with them and inform when is their turn. For pediatric patients, parents/guardians/accompanying persons should be in the smallest possible number, wear a protective mask at all times, wait in the waiting room, and not attend the patient's treatment to avoid the risk of aerosol inhalation.[14]


  Complications in Routine Dental Practice Top


Dental professionals are at an extremely high risk for transmission of COVID-19 infection. In dental practices, COVID-19 transmission is expected through droplets and aerosols generated during clinical procedures, especially when using drills or ultrasonic devices that cause aerosol release. Furthermore, splatters created during oral surgery procedures, such as aerosols, are also contaminated by respiratory pathogens.[15] Another important potential mode of transmission in dental practice could be contact with contaminated environmental surfaces. Furthermore, the shortage of PPEs is also a major challenge for dental clinics. More efforts are needed to ensure the supplies. To avoid any complications, dental clinics that lack PPEs should refer the suspected and confirmed patients to nearby dental clinics with sufficient quantity of PPEs to reduce the risk of infection.


  Handling of Patients with COVID-19 Symptoms Top


Every patient visiting the dental office should be considered a potent carrier of COVID-19. A proper medical history should be obtained from each patient. In the presence of fever detected in the past 14 days, positive epidemiological links, clinical signs, or symptoms related to COVID-19 (even with normal body temperature), it is preferable to reschedule non-urgent treatments after at least 14 days, recommending patients to contact their general practitioner for further investigation. It is also advisable to ask the patient to measure his/her body temperature every 8 hours starting from the day before the appointment and to postpone the appointment for at least 14 days if it goes over 37.3°C.[6] If necessary, it is advisable to schedule the appointment to the end of the day (maybe in a negative pressure or well-aerated room) using a dental rubber dam, avoiding all aerosol-generating procedures and minimizing intervention time. All disposable items including patient and workers PPE kits must be disposed of in a separate bag.[6] When intraoral imaging is required, sensors must be doubly covered to prevent perforation and must be correctly disinfected after use to avoid cross-contamination. All dental and surgical procedures should be carefully carried out to prevent coughing and gag reflexes. The treatment room door must be closed during interventions to avoid aerosol dispersion in other environments, especially if the air conditioning systems are switched on.[6]


  Caution Regarding Sterilization Top


The Centers for Disease Control (CDC) recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine dental healthcare delivery to all patients.[16] These practices are intended to apply to all patients, not just those with suspected or confirmed SARS-CoV-2 infection. CDC recommends using a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. Protective eyewear (e.g., safety glasses and trauma glasses) with gaps between glasses and the face likely do not protect eyes from all splashes and sprays.[16] The most important protocol to reduce aerosol spread into the operatory is the use of a rubber dam. It should comfortably cover the mouth and nose of the patient. It has been shown that the application of rubber dam alone reduces aerosol production up to 90%.[17] Surfaces can also be contaminated directly or indirectly by the deposition of droplet particles and the lifetime of the virus on surfaces varies depending on the materials and the presence of moisture.[18] It is advisable to utilize disinfectants that work on both airborne and blood-born viruses and microorganisms. The WHO guidelines recommend the use of 5% sodium hypochlorite, with a 1:100 dilution, to be applied on surfaces for an average action time of 10 min; constant ventilation of the dental surgery room is also recommended.[19]


  Dental Treatments at High, Medium, and Low Risk Top


The practice of dentistry involves the use of rotary dental and surgical instruments, such as handpieces or ultrasonic scalers and air-water syringes. These instruments create a visible spray that can contain particle droplets of water, saliva, blood, microorganisms, and other debris and lead to a higher risk of virus transmission. Surgical masks protect mucous membranes of the mouth and nose from droplet spatter, but they do not provide complete protection against inhalation of infectious agents.[16] Surgical procedures that might pose higher risk for SARS-CoV-2 transmission if the patient has COVID-19 include those that generate potentially infectious aerosols or involve anatomic regions where viral loads might be higher, such as the nose and throat, oropharynx, and respiratory tract.[16]


  Guidelines for Dental Assistants Top


Regardless of the type of treatment planned, healthcare professionals, including hygienists, and dental assistants, must follow rigid protocols related to dressing and PPE. Hair caps, protective goggles, surgical masks or N95, disposable surgical gowns, special footwears, and protective visors are essential.[14] All dental office/clinic workers (dentists, dental hygienists, assistants, and receptionists) must measure their body temperature daily, at least in the morning and in the evening. If the body temperature is higher than 37°C, the operator must not go to work, and sanitary observation should be activated.[6] Dental workers must enter the dental office/clinic wearing a surgical mask, then immediately put on shoe covers, throw the mask in a special closed container, and clean their hands with a disinfectant solution or with running water and soap, for at least 1 min. At the end of the procedure, it is essential for them to sanitize their hands again with disinfectant solution. All dental office/clinic workers must maintain social distancing of at least 1.5 m among them and always wear a surgical mask. They must avoid staying in common eating and relax areas, etc., at the same time unless for strictly necessary reasons.[6]


  Future Considerations Top


Dentistry still remains one of the most exposed professions COVID-19. Dental health care workers, including dentists, dental assistants, dental nurses, dental students, dental technicians, and laboratory technicians who are in direct clinical contact with patients need to get themselves vaccinated against the virus. However, vaccination is not the end. Postvaccination, we as dentists still need to religiously follow all sterilization and infection control measures, especially while performing aerosol-generating procedures. Dental staff education is essential for protecting staff and patients from further spread of COVID-19, with an emphasis on the progression of the disease, its mode of transmission, clinical presentation and prevention methods, proper training in hand hygiene, the use of PPE, and other recommended infection control measures.


  Conclusion Top


It is important for dentists to know the best practices for control of risks while performing dental procedures. The use of PPE does reduce rates of disease transmission. However, it does pose health hazards to practicing dentists which should also be taken into consideration. We should take certain measures to counteract the side effects of PPE which are relatively simple to follow and easy to apply while maintaining normal healthcare routine.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chopra SS, Pandey SS. Occupational hazards among dental surgeons. Med J Armed Forces India 2007;63:23-5.  Back to cited text no. 1
    
2.
Reddy KS, Majumder DS, Doshi D, Kulkarni S, Reddy S, Reddy MP. Occupational hazards in dentistry. J Res Adv Dent 2017;6:110-22.  Back to cited text no. 2
    
3.
Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020;579:270-3.  Back to cited text no. 3
    
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Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci 2020;12:9.  Back to cited text no. 4
    
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Fallahi HR, Keyhan SO, Zandian D, Kim SG, Cheshmi B. Being a front-line dentist during the COVID-19 pandemic: A literature review. Maxillofac Plast Reconstr Surg 2020;42:12.  Back to cited text no. 5
    
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Amato A, Caggiano M, Amato M, Moccia G, Capunzo M, De Caro F. Infection control in dental practice during the COVID-19 pandemic. Int J Environ Res Public Health 2020;17:4769.  Back to cited text no. 6
    
7.
Loibner M, Hagauer S, Schwantzer G, Berghold A, Zatloukal K. Limiting factors for wearing personal protective equipment (PPE) in a health care environment evaluated in a randomised study. PLoS One 2019;14:e0210775.  Back to cited text no. 7
    
8.
Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine 2020;99:e20603.  Back to cited text no. 8
    
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Honda H, Iwata K. Personal protective equipment and improving compliance among healthcare workers in high-risk settings. Curr Opin Infect Dis 2016;29:400-6.  Back to cited text no. 9
    
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Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus disease 19 (COVID-19): Implications for clinical dental care. J Endod 2020;46:584-95.  Back to cited text no. 13
    
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Villani FA, Aiuto R, Paglia L, Re D. COVID-19 and dentistry: Prevention in dental practice, a literature review. Int J Environ Res Public Health 2020;17:4609.  Back to cited text no. 14
    
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Coulthard P. The oral surgery response to coronavirus disease (COVID-19). Keep calm and carry on? Oral Surg 2020;13:95-7.  Back to cited text no. 15
    
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Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. [Last accessed on 04 Dec 2020].  Back to cited text no. 16
    
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Azim AA, Shabbir J, Khurshid Z, Zafar MS, Ghabbani HM, Dummer PM. Clinical endodontic management during the COVID-19 pandemic: A literature review and clinical recommendations. Int Endod J 2020;53:1461-71.  Back to cited text no. 17
    
18.
van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and surface stability of SARSCoV-2 as compared with SARS-CoV-1. N Engl J Med 2020;382:1564-7.  Back to cited text no. 18
    
19.
World Health Organization. Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Infections in Health Care; 2014. Available from: https://apps.who.int/iris/bitstream/handle/10665/112656/9789241507134_eng.pdf; jsessinid=C8857696E8E052600F0BEC469D387C20?sequence=1. [Last accessed on 2020 Apr 05].  Back to cited text no. 19
    




 

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Introduction
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