Infection control has hidden benefits for patients

Gloves can interfere with the spread of microbes that contaminate the hands of dental-team members from their own body surfaces, from previous patients, and from office surfaces.

Gloves can interfere with the spread of microbes that contaminate the hands of dental-team members from their own body surfaces, from previous patients, and from office surfaces.

Chris Miller, PhD,

Federally mandated infection-control procedures in health-care facilities concentrate on protection of the employees from exposure to human bodily fluids, such as blood and saliva in dentistry. This mandate comes from the Department of Labor`s OSHA division in the form of the 1991 Bloodborne Pathogens Standard. Very little is mentioned in this standard about patient protection, because OSHA is charged with protecting the workers of America, not patients.

However, some of these OSHA procedures designed to protect office staff have "hidden benefits" of also providing protection to patients. These include the use of most personal protective barriers (PPE), surface asepsis, and minimizing the spraying or spatter of blood/saliva.

Procedures not clearly described in the OSHA standard must be instituted to provide adequate patient protection. These include proper instrument-processing and sterilization-monitoring. Patient protection procedures (hidden and obvious) are described here.

Personal protective barriers

PPE is an OSHA phrase for the group barriers that give protection to the wearer (gloves, mask, protective clothing, protective eyeglasses). However, the wearing of gloves during patient treatment also provides protection to the patient in two ways. First, gloves prevent microbes on the skin of your hands from entering the patient`s mouth.

This is very important, because the hands are major culprits in spreading disease agents. Hands "go everywhere" and become grossly contaminated from contact with body surfaces and the environment. Although these transient microbes usually can be removed by thorough handwashing, handwashing is not always performed as thoroughly or frequently as needed. Thus, gloves can interfere with the spread of microbes that contaminate the hands of dental-team members from their own body surfaces, from previous patients, and from office surfaces.

A particularly good example of this type of patient-to-hands-to-patient spread has been reported (Manzella, JP et al. "An Outbreak of Herpes-Simplex Virus, Type-1 Gingivostomititis in a Dental-Hygiene Practice." J Am Med Assoc 1984; 252:2019-2222). A hygienist`s ungloved hands became contaminated with herpes virus from one patient presenting with an active fever blister. Dermatitis on the hygienist`s hands prevented handwashing to remove the virus, so it was spread to several subsequent patients because she did not routinely wear gloves. When gloves were worn, the spread of the virus stopped.

A second way of protection is that the gloves prevent any tissue fluids leaking through small cuts, abrasions, and "invisible" breaks in the skin. Bare fingers would become wet with the patient`s saliva. This would further facilitate transfer of fluids through these skin openings.

Analyses of previous case studies suggest that hepatitis B may have been transferred to patients from infected dentists who did not routinely wear gloves (Cottone, JA, Terezhalmy, GT, Molinari, JA. Practical Infection Control in Dentistry, 2nd edition, Williams and Wilkins, Baltimore, 1996, pp. 30-31).

Masks worn by the dental team prevent spatter from the patient`s mouth from contacting the membranes of the lips, mouth, and nose. They reduce inhalation of some microbes. In addition, the masks serve as at least a partial barrier between microbes in the respiratory tract of the dental-team member and the patient.

Protective clothing worn by dental-team members prevents contamination of their skin and underlying street/work clothing with microbes from the patient. This protective clothing also acts as a barrier between the patient and any microbes on the skin and street/work clothes of other team members.

Aseptic techniques - Several procedures other than the use of "personal protective" barriers can minimize the spread of microbes in the office. Examples of these procedures include proper positioning of the patient`s head, proper use of the air/water spray, and use of high-volume evacuation. Touching as few surfaces as possible with saliva-coated gloved hands also reduces the spread of microbes. Using dental treatment water with low microbial counts reduces contamination of patients with extraneous microbes.

Instrument-processing - One of the most obvious patient-protection mechanisms in the office is proper management of contaminated instruments before they are used on subsequent patients. This involves cleaning, rinsing, packaging, sterilization, storage, and distribution. In addition, patient protection in this area is monitored by the use of biological indicators (spore tests) and chemical indicators (markings on instrument packaging or autoclave tape). These monitoring systems determine the use and function of sterilizers to help assure patient protection.

Chris Miller, PhD, is professor of oral microbiology and executive associate dean at the Indiana University School of Dentistry.

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