Protective Attire

Aug. 1, 1996
Face it, hygienists are challenged every day by a myriad of factors while on the job. Chairside certainly has its joys and its hassles. While the mere mention of government regulations may fall into the latter category, hygienists can do things that will make their clinical life safer and easier. Take personal protective equipment (PPE), for example.

Getting dressed for work means making safe choices

Frances Wolfe

Face it, hygienists are challenged every day by a myriad of factors while on the job. Chairside certainly has its joys and its hassles. While the mere mention of government regulations may fall into the latter category, hygienists can do things that will make their clinical life safer and easier. Take personal protective equipment (PPE), for example.

Gone are the days of starched white dress uniforms, white hose, laced-up clinic shoes, and (God forbid!) starched white caps. Today, hygienists have a wider variety than ever to choose from when gearing up for the office. Government regulations regarding apparel are not really so difficult to comply with after all, especially when you know what`s required!

Protective attire for the dental hygienist

Gloves. According to the Centers for Disease Control and Prevention (CDC), medical gloves (latex or vinyl) must always be worn by dental health care workers (DHCWs) when there is potential for contacting blood, blood-contaminated saliva, or mucous membranes. Non-sterile gloves are acceptable for examinations and other nonsurgical procedures. Sterile gloves, however, should be used for surgical procedures - especially during periodontal surgery.

Before treating each patient, the hygienist should wash her hands and don fresh gloves. After treatment, or before leaving the operatory, the hygienist should remove and discard gloves, then wash her hands. DHCWs should always wash their hands and reglove between patients.

Surgical or examination gloves should not be washed before use; nor should they be washed, disinfected or sterilized for reuse. Washing of gloves may cause "wicking" (penetration of liquids through undetected holes in gloves) and is not recommended. Deterioration of gloves may be caused by disinfecting agents, oils, some oil- or petroleum-based lotions, and heat treatment such as autoclaving.

Face shields and masks. The splashing or splattering of blood or other body fluids is likely in dental hygiene. So chin-length plastic face shields or surgical masks and protective eyewear are required. When a mask is preferred, the hygienist should change it between patients or during treatment if it becomes visibly wet or moist. Face shields or protective eyewear should be washed with an appropriate cleaning agent and, when visibly soiled, disinfected between patients.

The hygienist is advised to choose a face mask that protects the respiratory system from particulates. Choose one that has both high filtration rates and a design that fits your face evenly to create an adequate seal. If you deem that further respiratory protection is necessary, such as when working in the lab, protect yourself from fine dusts, mists, or harmful vapors with a respirator specific to your needs. For example, an organic vapor respirator with a dust/mist pre-filter provides an "all-in-one" solution for sufficient protection in the lab.

Eyewear. Prescription glasses are insufficient protection for hygienists who require corrective lenses. The frames must be sturdy with intact side shields. Or you may wear goggles over your prescription glasses.

Protective clothing. Reusable or disposable gowns, laboratory coats, or uniforms are worn when clothing is likely to be soiled with blood or other body fluids. Fluid-resistant attire is required when working in an environment where periodontal surgery is performed. Generally, polyester-cotton blend fabrics are considered fluid-resistant.

Reusable protective clothing should be washed with a normal laundry cycle, according to the instructions of detergent and machine manufacturers. Protective clothing should be changed at least daily, or as soon as it becomes visibly soiled.

Throughout this article, the term, "visibly soiled," relies on a subjective judgment. To the author, visibly soiled would mean dirty enough to be motivated to change the clothes currently being worn. If, for example, flecks of blood or other staining material were observable by someone else - a staff member or patient at conversational distance - then it`s probably time to change into fresh clothes.

The employer is required to assume laundry and dry cleaning costs associated with reusable clinic attire, such as scrubs, lab jackets, and uniforms. Contaminated PPE should be handled as little as possible and stored in marked containers. Protective garments and devices (including gloves, masks, and eye and face protection) should always be removed before the hygienist leaves the office.

Protective barriers. Impervious-backed paper, aluminum foil, or plastic covers protect, for example, light handles or X-ray unit heads that may become contaminated by blood or saliva and that are difficult or impossible to clean and disinfect. Between patients, these coverings should be removed (while the hygienist is wearing gloves), discarded appropriately, and replaced (after ungloving and washing of the hands) with clean material.

Appropriate use of dental dams, high-velocity air evacuation, and proper patient positioning help minimize the formation of droplets, splatter, and aerosols routinely associated with treatment.

In addition, splash shields are worn when working in the dental laboratory area.

Care of the hygienists` hands

Hygienists have always been concerned about hand care. All DHCWs, especially hygienists, should wash their hands before and after treating each patient (before glove placement and after glove removal), as well as after barehanded touching of inanimate objects likely to be contaminated by blood, saliva, or respiratory secretions. Hands are washed after removing gloves since gloves may become perforated during treatment.

Soap and water will remove transient microorganisms acquired directly or indirectly through patient contact. For most routine procedures, such as examinations and nonsurgical procedures, handwashing with plain soap and warm to hot water is adequate. For surgical procedures, an antimicrobial surgical handscrub with residual action should be used.

If the gloves are torn, cut, or punctured, the hygienist should remove them as soon as patient safety permits. The hygienist should wash her hands thoroughly and reglove to complete the procedure. Hygienists with exudative lesions or weeping dermatitis, especially on their hands, should refrain from both treatment and handling dental equipment until the condition clears up.

Proper handling of sharp instruments and needles

While not technically a form of PPE, hygienists should be familiar with proper handling and disposal of sharp items she may contact during and immediately following the course of patient treatment. Sharps (needles, scalpel blades, burs, or orthodontic wires) contaminated with patient blood or saliva should be considered as potentially infective. They need to be handled with care to prevent injuries such as percutaneous needlesticks and cuts.

According to RDH readers responding to Cathleen Terhune`s March 1996 article, "Needles and the Rush Hour," which discussed sharps incidents, the most common occurrences of accidental exposure involving hygienists and sharps included:

- Non-specific hand-instruments - 40 percent.

- Ultrasonic instrument tips - 27 percent.

- Needles - 13 percent.

- Scalers - 13 percent.

- Curettes - 7 percent.

According to the CDC, used needles should never be recapped or otherwise manipulated by using both hands, or any other technique that involves directing the point of a needle toward any part of the body. Either a one-handed "scoop" technique or a mechanical device designed to hold the needle sheath works best.

Contaminated disposable syringes and needles, scalpel blades, and other sharps are placed in appropriate puncture-resistant containers located as close as is practical to the area where the items are used. Bending or breaking needles before disposal is not recommended. Before removing needles from non-disposable aspirating syringes, DHCWs should recap them to prevent injuries.

For procedures involving multiple injections using a single needle, the unsheathed needle should be placed in a location where it will not become contaminated or contribute to unintentional percutaneous needlesticks between injections. Often, the intact syringe is placed back on the instrument tray. Other hygienists prefer to take it out of the immediate field of operation, placing it on the countertop or mobile cart and covering the syringe with a towel.

If the decision is made to recap a needle between injections, a one-handed "scoop" technique or a mechanical device designed to hold the needle sheath is recommended.

Complying with infection control appears time-consuming to busy practices. Suggestions to resolve time limits have ranged from hiring an assistant for the hygienist, rotating back and forth between two operatories, or merely just hoping a quick wipe-down is effective. A suggestion that makes more sense is for the practice to hire an infection control coordinator. The coordinator ro-tates all operatories based on scheduling and time required to tear down, prepare, and set up the equipment.

Today`s hygienist can feel safe and comfortable when following simple, step-by-step guidelines for PPE. For more information, contact your OSHA office. The federal and state occupational health agencies are shedding the image of being "police officers" who "patrol" employers and are now focused on assisting workers in preventing injuries and illnesses. Their representatives are there to help you.

Frances Wolfe is a pen name for a long-time dental editor.

The latest requirements from OSHA regarding PPE

In the 1994 Standard, which was made final in 1995, the Occupational Safety and Health Administration designates six provisions concerning PPE:

(1) Application - Protective equipment (including PPE for the eyes, face, head, and extremities), protective clothing, respiratory devices, and protective shields and barriers shall be provided, used, and maintained in a sanitary and reliable condition, wherever it is necessary by reason of hazards of processes or environment, chemical hazards, radiological hazards, or mechanical irritants encountered in a manner capable of causing injury or impairment in ... any part of the body through absorption, inhalation, or physical contact.

(2) Employee-owned equipment - Where employees provide their own protective equipment, the employer shall be responsible to ensure its adequacy, including proper maintenance and sanitation of such equipment.

(3) Design - All PPE shall be of safe design and construction for the work to be performed.

(4) Hazard assessment and equipment selection - The employer shall assess the workplace to determine if hazards are present, or are likely to be present, which necessitate the use of PPE. If such hazards are present, or likely to be present, the employer shall first:

__ Select and have each affected employee use the types of PPE that will protect the affected employee from the hazards identified in the hazard assessment;

__ Communicate selection decisions to each affected employee;

__ Select PPE that properly fits affected employees.

Second, the employer shall verify that the required workplace hazard assessment has been performed through a written certification that identifies the workplace evaluated; the person certifying that the evaluation has been performed; the date(s) of the hazard assessment; and which identifies the document as a certification of hazard assessment.

(5) Defective and damaged equipment - Defective or damaged PPE shall not be used.

(6) Training - The employer shall provide training to each employee who is required to use PPE. Each employee shall be trained to know at least the following:

__ When PPE is necessary.

__ What PPE is necessary.

__ How to properly put on, take off, and adjust and wear PPE.

__ The limitations of the PPE.

__ The proper care, maintenance, useful life, and disposal of the PPE.

Each affected employee shall demonstrate an understanding of the training specified and the ability to use PPE properly, before being allowed to perform work requiring the use of PPE. When the employer has reason to believe that any affected employee who has already been trained does not have the understanding and skill required concerning the wearing and use of PPE, the employer shall retrain each employee concerning changes in the workplace that render training obsolete; or changes in the types of PPE to be used render previous training obsolete; or inadequacies in an affected employee`s knowledge or use of assigned PPE indicate that the employee has not retained the requisite understanding or skill.

The employer shall verify that each affected employee has received and understands the required training through a written certification that contains the name of each employee trained, the date(s) of training, and that identifies the subject of the certification.

Latex alternatives for gloves

One challenge that has surfaced for all DHCWs, especially hygienists, is the myriad of hand problems associated with wearing gloves as a requirement for proper PPE. Increased glove use has brought about a significant increase in allergic reactions associated with gloves.

While you can`t give up wearing gloves at work, here are some common sense guidelines from Wava Truscott, PhD, vice president of Safeskin Corporation in San Diego. Her suggestions may help alleviate the symptoms associated with latex allergy and irritation. Note, to confirm a true allergy to latex, a test is now available, which can be ordered by an allergist or dermatologist for a definitive diagnosis. In the meantime, the following measures can protect your hands and alleviate some of the signs and symptoms associated with latex sensitivity:

- Select a glove that is low in latex protein allergens to help prevent the development of immediate type hypersensitivity.

- Choose a hypoallergenic glove low in chemical residuals to prevent the onset of irritant and allergic contact dermatitis.

- Wear a glove that`s snugly comfortable, but not baggy.

- Purchase a glove that will last throughout the procedure. Collect statistics about failure rates, donning tear rates and in-use failure when trying various products.

- Opt for powder-free/chlorine-free gloves to eliminate powder and chlorine irritation complications.

- Choose a glove with a textured grip. This helps prevent slippage and reduces day-end hand fatigue that is sometimes associated with the signs and symptoms of carpal tunnel syndrome.

- Choose a glove with a beaded cuff to ease removal from the box and donning while reducing roll-down. Note: Make sure the cuff of the glove reaches beyond and covers the cuff of the scrub top or lab jacket to ensure protection of intact skin.

- Carefully consider cost-effectiveness when choosing a glove. Weigh the lost time, workers compensation, repeated procedures, and other associated post-procedural complications associated with glove use against the cost.