By early March 2020, it had become clear that the COVID-19 pandemic was taking a strong hold around the world, especially in the United States. As a result, the American Dental Association (ADA), the Centers for Disease Control and Prevention (CDC), and numerous state and local health authorities recommended or required that all dental procedures be suspended except for care involving emergency and urgent needs. Now, months into the pandemic and as dental offices have resumed routine dental procedures, it is worthwhile to review the changes in personal protective equipment (PPE) to help ensure the safety of patients and dental health care personnel (DHCP).
A 2020 poll of more than 19,000 dentists conducted by the ADA Health Policy Institute showed that by March 23, 76% of US dental offices had closed to all but emergency care, 19% were not seeing any patients, and 5% were open but no longer seeing the same volume of patients.1 By the beginning of July, nearly 70% of dentists polled by the Health Policy Institute indicated they were back working about the same number of hours as before the pandemic.2 A critical aspect of resuming routine dental care is the need for adequate and appropriate PPE.
During the time that most dental offices were only providing emergency care, interim recommendations for infection prevention and control precautions provided guidance on how to safely treat patients with urgent needs. As time passed, additional recommendations provided information needed to resume routine care of patients.3-5 An important and prominent element of returning to patient care was adjusting and expanding the use of PPE. The use of standard precautions in the care of dental patients had long been the recommended approach.6 Standard precautions alone, however, cannot prevent all disease transmission because they are focused on avoiding contact with patients’ body fluids through contact with mucous membranes and nonintact skin and via percutaneous injury such as a needlestick. For some infectious diseases, a second tier of precautions called “transmission-based precautions” is needed. Transmission-based precautions are necessary when caring for patients with infectious diseases that transmit via contact, droplet, or airborne transmission.7 COVID-19 is believed to be most likely transmitted by contact with infectious droplets, but it may also transmit via the airborne route.8
Dental procedures often involve aerosol-generating procedures. The greatest number of aerosols are generated during restorative and preventive procedures involving the use of handpieces and ultrasonic scalers.9 For that reason, it is currently recommended that the use of ultrasonic scalers be suspended.4 Components of dental aerosols include water, blood, microorganisms, mucosal cells, restorative materials, tooth particles, and large quantities of saliva.10 Owing to the nature of dental procedures, DHCP must be near the source of these aerosols while providing patient care. PPE is an important element of both standard and transmission-based precautions. The current focus on PPE is an opportunity to ensure DHCP are using and managing PPE appropriately. Hand hygiene is closely connected to PPE and should be per formed before donning and after removing PPE.
Gowns and Protective Clothing
Surgical gowns, laboratory coats, and other protective attire have long been recommended for the protection of DHCP during procedures that generate spray or spatter from the patient’s mouth.6,11,12 During the COVID-19 pandemic, government agencies and professional organizations have reinforced and clarified the need to wear protective attire that will help prevent personal clothing and skin (for example, forearms) from becoming soiled with blood, saliva, or other potentially infectious materials.3-5 Gowns should be changed if they become soiled. Disposable gowns should be discarded after use, and reusable gowns, such as cloth gowns, should be collected in a designated container for laundering.4
For nonsurgical dental procedures, DHCP may use nonsterile medical examination gloves. Gloves should be placed last in the sequence of donning PPE and should be changed if they become torn or heavily contaminated.4 For surgical procedures, DHCP should wear sterile surgeon’s gloves. For oral surgical procedures, perform surgical hand antisepsis before donning gloves. Use either an antimicrobial soap and water, or soap and water followed by drying hands and then applying an alcohol-based surgical handscrub.6
DHCP should wear eye protection that will prevent debris from dental procedures contacting the mucous membranes of their eyes. Goggles that do not have gaps and provide side protection or a full face shield that also protects the side of the wearer’s face are recommended.4 The CDC interim guidance suggests that DHCP working in locations where there is moderate to substantial transmission of COVID-19 also wear eye protection as source protection.4 This means that eye protection would be worn to protect against respiratory droplets and aerosols even when performing procedures that do not generate spray or spatter, such as examinations.4
Many DHCP wear magnification loupes during dental procedures, which can make it difficult to wear goggles or a close-fitting face shield. When wearing a face shield over loupes, ensure that the face shield does not have gaps (for example, for headlamps), and that it provides adequate side protection. Reusable eye protection should be cleaned or disinfected between patients according the manufacturer’s instructions for use.4
Masks and Respiratory Protection
The CDC interim guidance suggests that dental practices in locations where there is no to minimal community transmission may continue to use surgical masks for protection when performing procedures that may generate splashes or spatter of blood or other body fluids.4 Surgical masks are cleared by the US Food and Drug Administration (FDA) and meet standards set by ASTM International, an international standards organization that develops and publishes voluntary consensus technical standards for a wide range of materials, products, systems, and services. Surgical masks are assigned 3 levels, depending on their ability to filter fine particles, breathability, fluid resistance, and flame spread. All 3 levels are appropriate for health care uses but differ primarily in their ability to resist fluid (Figure 1).
Click here to view the full-sized graphic for Figure 1.
In locations where there is moderate to substantial community transmission, the CDC recommends the use of respirators to provide at least the level of N95 filtering facepiece respirators during aerosol-generating procedures.4 Before using respirators, employers must establish a written respiratory protection program, offer medical evaluation, fit testing, and provide training for all employees using the respirators in compliance with the Occupational Safety and Health Administration respiratory protection standard.13 The standard also requires annual fit testing for employees using respirators. The Occupational Safety and Health Administration has advised compliance and enforcement officers that they can temporarily exercise discretion in enforcement of the annual fit test requirement due to shortages of N95 and other respirators.14 However, the initial fit testing is still required. Surgical masks protect from splashes and spatter and provide some source control but are not considered respiratory protection. Respirators, such as the N95, must be worn correctly, inspected before each use, and have a user seal check before each use. Figure 2 depicts the proper way to don, seal check, and remove an N95 respirator.
Click here to view the full-sized graphic for Figure 2.
Respirators are tested by the National Institute for Occupational Safety and Health, and respirators intended for medical use are cleared by the FDA. During the COVID-19 pandemic, the FDA allowed emergency use authorization for some respirators that have not been tested by the National Institute for Occupational Safety and Health. The FDA maintains a list of respirators authorized under this emergency use authorization on its website.
In some locations, cases of COVID-19 surged rapidly and left health care workers with limited supplies of necessary materials, including PPE. Because of high demand, shortages of PPE were soon widespread. As a result, CDC issued recommendations for optimization of PPE during shortages caused by the COVID-19 pandemic.15 Some of the strategies include extending the use or reusing PPE that is normally considered single use or disposable.
PPE optimization strategies are only intended for times when there are shortages of PPE and should not be adopted as routine practice.16 These strategies take a tiered approach, identifying 3 separate capacity scenarios: conventional, contingency, and crisis. Under conventional capacity adequate supplies are available, and there is no need to alter the use of PPE. For contingency and crisis capacity, some compromises are made due to shortages only after other control measures have been instituted (Figure 3).
Click here to view the full-sized graphic for Figure 3.
Training in Donning and Doffing PPE
Having the correct PPE is critically important, but the proper use of this equipment is arguably just as important. The manner and sequence in which DHCP don and remove PPE should focus on proper fit, placement, and removal of PPE to minimize the risk of contaminating the wearer’s face, skin, and clothing. DHCP should also ensure PPE, such as gloves that will contact the patient, remain uncontaminated from sources such as equipment and environmental surfaces. Several suggested sequences for donning and removing PPE exist and should be adapted to the needs and environment of the care setting. One such suggested sequence is depicted in Figure 4.
Click here to view the full-sized graphic for Figure 4.
Ideally, training will include demonstration and practice of important aspects of PPE, including when to use PPE; what PPE is necessary; how to properly don, use, and doff PPE in a manner to prevent self-contamination; how to properly dispose of or disinfect and maintain PPE; and the limitations of PPE.4
Checklists are available from the ADA and the Organization for Safety, Asepsis and Prevention (OSAP) that will assist in the training of DHCP in using PPE during the COVID-19 pandemic. Additional resources are available in the ADA’s Return to Work Interim Guidance Toolkit,5 and the OSAP’s OSAP/DQA Best Practices for Infection Control in Dental Clinics during COVID-19 Pandemic.3
About the author
Eve Cuny, MS, is the Executive Associate Dean and an associate professor at Arthur A. Dugoni School of Dentistry, University of the Pacific, San Francisco, California. Ms. Cuny is a member of the National Occupational Research Agenda Council, and she has served as a reviewer and subject matter expert for the Centers for Disease Control and Prevention. She has worked in the area of dental infection prevention and patient safety for the past 30 years. Ms. Cuny is also a member of the board of directors of the Organization for Safety, Asepsis and Prevention.
1. Carey M. HPI poll examines impact of COVID-19 on dental practices: data to help shape ADA response to pandemic. ADA News. April 1, 2020. Accessed September 7, 2020.
2. Carey M. Eighth wave of HPI poll shows dental care rebound slowing down. ADA News. July 9, 2020. Accessed September 7, 2020.
3. OSAP/DQP. Best Practices for Infection Control in Dental Clinics During the COVID-19 Pandemic. Accessed September 6, 2020.
4. Center for Disease Control and Prevention. Guidance for Dental Settings: Interim Infection Prevention and Control Guidance for Dental Settings During the Coronavirus Disease 2019 (COVID-19) Pandemic. Updated Aug. 28, 2020. Accessed September 7, 2020.
5. ADA. Get the Return to Work Interim Guidance Toolkit. Accessed July 23, 2020.
6. Kohn WG, Collins AS, Cleveland JL, et al.; Centers for Disease Control and Prevention (CDC). Guidelines for infection control in dental health-care settings: 2003. MMWR. 2003;52(RR-17):1-61.
7. Siegel JD, Rhinehart E, Jackson M, Chiarello L; the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Accessed September 21, 2020.
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10. Zemouri C, de Soet H, Crielaard W, Laheij A. A scoping review on bio-aerosols in healthcare and the dental environment. PLoS One. 2017;12(5):e0178007.
11. CDC. Recommended infection-control practices for dentistry. MMWR. 1986;3(15)5:237-242.
12. CDC. Recommended infection-control practices for dentistry, 1993. MMWR. 1993;42(RR-8):1-12.
13. OSHA. Respiratory Protection. OSHA 3027. 2002 (revised). Accessed September 6, 2020.
14. United States Department of Labor, Occupational Safety and Health Administration. Temporary Enforcement Guidance: Healthcare Respiratory Protection Annual Fit-Testing for N95 Filtering Facepieces During the COVID-19 Outbreak. March 14, 2020. Accessed September 6, 2020.
15. Centers for Disease Control and Prevention. Optimizing Personal Protective Equipment (PPE) Supplies. July 16, 2020. Accessed September 7, 2020.
16. Centers for Disease Control and Prevention. Summary for Healthcare Facilities: Strategies for Optimizing the Supply of PPE During Shortages. Accessed September 7, 2020