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Interim Dental Infection Prevention and Control Guidance for the COVID‑19 Response – A New Paradigm
Using Personal Protective Equipment (PPE)

Course Author(s): Michaell A. Huber, DDS

Using Personal Protective Equipment (PPE)

Ensure office personnel are trained to determine the proper selection and appropriate use of PPE to reduce the risk of patient and office personnel exposure to SARS‑CoV‑2.2

  • Employers should select appropriate PPE and provide it to OHCP in accordance with Occupational Safety and Health Administration PPE standards (29 CFR 1910 Subpart I).18 OHCP must receive training on and demonstrate an understanding of:
    • when to use PPE;
    • what PPE is necessary;
    • how to properly don, use, and doff PPE in a manner to prevent self-contamination (Box A);19
    • how to properly dispose of or disinfect and maintain PPE;
    • the limitations of PPE.
  • Dental facilities must ensure that any reusable PPE is properly cleaned, decontaminated, and maintained after and between uses. Dental settings also should have policies and procedures describing a recommended sequence for safely donning and doffing PPE.

For OHCP working in facilities located in areas with no to minimal community transmission

  • DHCP should continue to adhere to Standard Precautions (and Transmission-Based Precautions, if required based on the suspected diagnosis).
  • OHCP should wear a surgical mask, eye protection (goggles, or a face shield that covers the front and side of the face), a gown or protective clothing, and gloves during procedures likely to generate splashing or spattering of blood or other body fluids. Protective eyewear with gaps between glasses and the face likely do not protect eyes from splashes and sprays.

For OHCP working in facilities located in areas with moderate to substantial community transmission

  • DHCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), DHCP should follow Standard Precautions (and Transmission-Based Precautions, if required based on the suspected diagnosis).
  • DHCP should implement the use of universal eye protection and wear eye protection in addition to their surgical mask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters, including those where splashes and sprays are not anticipated.
  • For aerosol-generating procedures, DHCP should use an N95 respirator20 or a respirator that offers an equivalent or higher level of protection such as other disposable filtering facepiece respirators, PAPRs, or elastomeric respirators.21
    • Respirators should be used in the context of a respiratory protection program, which includes medical evaluations, training, and fit testing.22
    • Respirators with exhalation valves should not be used for source control as unfiltered exhaled breath may compromise the sterile field during surgery. If only a respirator with exhalation valve is available and source control is needed, the exhalation valve should be covered with a facemask that does not interfere with the respirator fit.
Box A. Suggested sequence for donning and doffing PPE:19

Before entering a patient room or care area:

  1. Perform hand hygiene.
  2. Put on a clean gown or protective clothing that covers personal clothing and skin (e.g., forearms) likely to be soiled with blood, saliva, or other potentially infectious materials.
    • Gowns and protective clothing should be changed if they become soiled.
  3. Put on a surgical mask23 or respirator.
    • Mask ties should be secured on the crown of the head (top tie) and the base of the neck (bottom tie). If the mask has loops, hook them appropriately around your ears.
    • Respirator straps should be placed on the crown of the head (top strap) and the base of the neck (bottom strap). Perform a user seal check each time you put on the respirator.
  4. Put on eye protection.
    • Personal eyeglasses and contact lenses are NOT considered adequate eye protection.
  5. Put on clean non-sterile gloves.
    • Gloves should be changed if they become torn or heavily contaminated.
  6. Enter the patient room.

After completion of dental care:

  1. Remove gloves.
  2. Remove gown or protective clothing and discard the gown in a dedicated container for waste or linen.
    • Discard disposable gowns after each use.
    • Launder cloth gowns or protective clothing after each use.
  3. Exit the patient room or care area.
  4. Perform hand hygiene.
  5. Remove eye protection.
    • Carefully remove eye protection by grabbing the strap and pulling upwards and away from head. Do not touch the front of the eye protection.
    • Clean and disinfect reusable eye protection according to manufacturer’s reprocessing instructions prior to reuse.
    • Discard disposable eye protection after use.
  6. Remove and discard surgical mask or respirator.
    • Do not touch the front of the respirator or mask.
    • Surgical mask: Carefully untie the mask (or unhook from the ears) and pull it away from the face without touching the front.
    • Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.
  7. Perform hand hygiene.

PE Supply Optimization Strategies:

Major distributors in the United States have reported shortages of PPE, especially surgical masks and respirators. The anticipated timeline for return to routine levels of PPE is not yet known. The CDC has developed a series of strategies or options to optimize supplies of PPE24 in healthcare settings when there is limited supply, and a burn rate calculator25 that provides information for healthcare facilities to plan and optimize the use of PPE for response to the COVID‑19 pandemic. Optimization strategies are provided for gloves, gowns, facemasks, eye protection, and respirators.

These policies are only intended to remain in effect during times of shortages during the COVID‑19 pandemic. OHCP should review this guidance carefully, as it is based on a set of tiered recommendations. Strategies should be implemented sequentially. Decisions by facilities to move to contingency and crisis capacity strategies are based on the following assumptions:

  • Facilities understand their current PPE inventory and supply chain;
  • Facilities understand their PPE utilization rate;
  • Facilities are in communication with local healthcare coalitions and federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) regarding identification of additional supplies;
  • Facilities have already implemented engineering and administrative control measures;
  • Facilities have provided OHCP with required education and training, including having them demonstrate competency with donning and doffing, with any PPE ensemble that is used to perform job responsibilities, such as provision of patient care.

For example, extended use of facemasks and respirators should only be undertaken when the facility is at contingency or crisis capacity and has reasonably implemented all applicable administrative and engineering controls. Such controls include selectively canceling elective and non-urgent procedures and appointments for which PPE is typically used by OHCP. Extended use of PPE is not intended to encourage dental facilities to practice at a normal patient volume during a PPE shortage, but only to be implemented in the short-term when other controls have been exhausted. Once the supply of PPE has increased, facilities should return to standard procedures.

Respirators that comply with international standards may be considered during times of known shortages. CDC has guidance entitled “Factors to Consider When Planning to Purchase Respirators from Another Country”26 which includes a webinar and Assessments of International Respirators.

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