Pandemic Response Puts PPE Under the Microscope

Kathy Eklund, RDH, MHP (KE): It remains to be seen what guidance the US Centers for Disease Control and Prevention (CDC) will provide after the pandemic. Obviously, we have a much better understanding of how PPE protects personnel and patients. PPE and respiratory protection during aerosol-generating procedures should be considered going forward. We have learned a lot, and dental healthcare professionals are much more aware of the proper way to wear PPE (ie, donning and doffing) than they were prior to the pandemic.

ID: What are some of the most noteworthy developments in PPE products, whether during COVID-19 or even in recent years prior to the pandemic?

KE: As a profession, we are now far more aware of PPE standards and how PPE is manufactured. The United States has relied on the importation of PPE from other countries for many years. During this pandemic, it became clear that more of the manufacturing needs to occur in the United States, especially after the shortages and other issues that have occurred. Many companies from other industries have stepped forward to help, including toy manufacturers making face shields, clothing manufacturers making face masks and isolation gowns, and more. It will be interesting to see what kind of support there is for manufacturing in the United States. Technically, the PPE used in healthcare settings needs to be cleared by the US Food and Drug Administration, but during the pandemic, we have seen emergency use authorizations. Those are temporary, however, so we will have to wait to see how things will develop in that regard.

ID: Are there any common misconceptions about PPE and its use that should be cleared up?

KE: The most significant misunderstanding that I am aware of involves PPE optimization. The extended use of respirators, barrier attire, etc should only be undertaken when the facility is at contingency or crisis capacity and has reasonably implemented all applicable administrative and engineering controls, which means pulling back from procedures. CDC's website offers a PPE Burn Rate Calculator that you can use to examine your inventory and your scheduled appointments to determine how far you can go before needing to implement controls, such as selectively canceling elective and nonurgent procedures and appointments for which PPE is typically used by dental healthcare personnel. The guidelines for the extended use of PPE should not encourage dental facilities to practice at a normal patient volume during a PPE shortage; they are 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.

ID: The dental setting obviously presents some unique challenges. What are some of the ways that PPE can be adapted or best utilized in order to avoid disrupting the workflow?

KE: The CDC has a list, but facilities really need to understand their current PPE inventory and supply chain. The PPE Burn Rate Calculator is very useful not only during shortages but at any time for inventory control in general. A facility that understands its PPE utilization rate will be much better able to do those calculations. In addition, facilities need to be in communication with health authority coalitions-including federal, state, and local public health partners, such as public health emergency preparedness and response staff-regarding standards because although the CDC offers guidance, part of that guidance is a framework to consider your local epidemiology of spread and to ensure that you know what your state's guidance is. For example, Massachusetts has very specific guidance based on which phase of reopening that the state is in.

ID: What developments do you think we might see in the near or long-term future regarding advanced PPE for dental settings?

KE: We will likely see more US manufacturing of PPE. Many of these products require human labor to manufacture as opposed to automated processes, and labor costs have been lower in China and Southeast Asia ever since the demand for PPE began increasing in the 1990s with the advent of the Occupational Safety and Health Administration's (OSHA) Bloodborne Pathogens Standard and CDC guidance. However, we have now seen the need for this equipment to be manufactured in the United States. The other development will be determining what PPE will be used for things like aerosol-generating procedures in the future and defining what those are in dentistry. For many years, we have been faced with influenzas and common colds, but the need for additional PPE during aerosol-
generating procedures is something that may be reconsidered after the pandemic.

ID: How should staff training for PPE (ie, donning, doffing, fit testing for N95s, infection control procedures) be conducted for new hires and on an ongoing basis?

KE: There should be clear, written policies and procedures that are used to provide training for new personnel and at least annual training for existing staff. These should encompass the selection and use of PPE in terms of proper fit, sequencing, donning, and doffing. Respirators should be used in the context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing, and training in accordance with OSHA's Respiratory Protection Standard.¹ Dental settings can partner with occupational health programs to provide the medical evaluation and do the fit testing. Respirators with exhalation valves are not recommended for source control and should not be used during surgical procedures because unfiltered exhaled breath may compromise the sterile field. If only a respirator with an exhalation valve is available and source control is needed, the exhalation valve should be covered with surgical tape and a facemask that does not interfere with the fit of the respirator. You do not want the provider breathing through the exhalation valve and putting the patient at increased risk of exposure.

ID: What needs to be communicated to patients regarding PPE (eg, patient masks, office procedures, reducing anxiety), and how is this best accomplished?

KE: Dental settings should have multiple levels of communications to patients (eg, information on websites, answering patient questions by phone, etc.) to explain site-specific procedures during the pandemic, including screening, teledentistry, PPE, cleaning and disinfection, enhanced ventilation, and any other relevant changes. It is important for patients to be aware of the measures that are being taken so that they feel safe in their environment. Practices should be in compliance with interim CDC Guidance for Dental Settings.² In addition, the Organization for Safety, Asepsis and Prevention (OSAP) has collaborated with the DentaQuest Partnership to develop a plain language resource for patients.³ It is a short document that is easy to read and easily accessible. It can be posted on a practice's website and/or provided in print form to patients.

Kathy Eklund, RDH, MHP
Director of Occupational
Health and Safety
The Forsyth Institute