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Personal Protective Equipment and the provision of Urgent Dental Care in

Yorkshire & Humber

Reducing the risk of transmission of COVID-19 Version 4.0 Updated 22nd June 2020. Any updates will be highlighted below. 22/06/20 *Major update to match transition to recovery SOP*

• Updated: PPE for dental care (including information on Test and Trace), Sessional Use of PPE, PPE for decontamination & AGPs in dentistry

• Added new sections: Reusable gowns, Medical emergencies and CPR, Filtering face piece respirators, valved/unvalved respirators, choosing a respirator and where clinical staff have facial hair, religious head coverings or failed fit testing sections

• Added new joint statement by BSP/FGDP/ODCO regarding dental prophylaxis 26/04/20 – PHE statement confirming that chest compressions are not an AGP (24/04/20) added to section ‘What are AGPs in relation to dentistry?’ 29/04/20 – NERVTAG evidence review and consensus regarding CPR as an AGPs

Table of Contents

Purpose ............................................................................................................................ 2

Why do I need training in Personal Protective Equipment (PPE)? ....................................... 2

What PPE should I wear for each setting and context? ...................................................... 3

PPE for dental care ................................................................................................................... 3

Sessional use of PPE ................................................................................................................. 5

Reusable gowns ....................................................................................................................... 7

PPE whilst performing decontamination of the dental surgery .................................................. 7

What is an aerosol generating procedure (AGP)? .............................................................. 9

Background: Modes of transmission of COVID-19 ..................................................................... 9

What are AGPs in relation to dentistry? .................................................................................. 10

Joint statement by BSP/FGDP/ODCO regarding dental prophylaxis ......................................... 10

Medical emergencies and CPR ................................................................................................ 11

Respirator or surgical mask – what is the difference? ...................................................... 12

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Fluid-resistant (Type IIR) surgical masks (FRSMs) .................................................................... 12

Filtering face piece respirators (FFP3/FFP2/N95) ..................................................................... 12

Valved/unvalved respirators .................................................................................................. 13

Choosing a respirator ............................................................................................................. 14

Where clinical staff have facial hair, religious head coverings or have failed fit testing ............. 15

Eye and face protection .................................................................................................. 16

Disposable Gloves........................................................................................................... 17

What is ‘donning’ and ‘doffing’ and how do I do it? ........................................................ 17

Donning and doffing for AGPs ................................................................................................ 17

Donning and doffing for non-AGPs ......................................................................................... 22

Hand hygiene, what do I need to know? ......................................................................... 26

Purpose The purpose of this document is to summarise the national COVID-19 guidance and standard operating procedure for dental care (Transition to recovery) published by NHS England & NHS Improvement (NHS E & NHS I) and the Public Health England (PHE) guidance in relation to Personal Protective Equipment in urgent dental care. Please note that this summary is based purely on PHE and NHS E & NHS I national guidance which is regularly updated. Therefore, all members of the dental team must regularly review the full guidance via the links below to ensure they continue to treat patients safely during the COVID-19 pandemic. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe https://www.england.nhs.uk/coronavirus/primary-care/dental-practice/

Why do I need training in Personal Protective Equipment (PPE)? At a time when there is currently sustained community transmission of COVID-19 in the UK, the likelihood of any patient having coronavirus infection is raised. The transmission of COVID-19 is thought to occur mainly through respiratory droplets generated by coughing and sneezing, and through contact with contaminated surfaces. Airborne transmission can occur where aerosol generating procedures (AGPs) are performed. Therefore, dependent on the context, the standard PPE measures routinely used in dentistry may be insufficient to prevent transmission of COVID-19. Transmission based precautions are applied when standard infection control precautions alone are insufficient to prevent cross transmission of an infectious agent (PHE).

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Interrupting transmission of COVID-19 requires both droplet and contact precautions; if an aerosol generating procedure (AGP) is being undertaken then airborne precautions are required in addition to contact precautions (PHE). PHE describe safe ways for working for all health and care workers during the COVID-19 pandemic. This includes:

• Staff should be trained on donning and doffing PPE. Videos are available for training.

• Staff should know what PPE they should wear for each setting and context

• Staff should have access to the PPE that protects them for the appropriate setting and context

• Gloves and aprons are subject to single use as per Standard Infection Control Precautions with disposal after each patient or resident contact

• Fluid repellent surgical mask and eye protection can be used for a session of work rather than a single patient or resident contact (Please see sessional use section)

• Hand hygiene should be practiced and extended to exposed forearms, after removing any element of PPE

• Staff should take regular breaks and rest periods

What PPE should I wear for each setting and context?

PPE precautions now need to be taken for all patient encounters at a time when there is sustained community transmission of COVID-19 and the likelihood of any patient having coronavirus infection is raised.

Within an urgent dental care setting, the level of PPE that should be worn should be based on a risk assessment by the dental team with regards to the risk to themselves and the dental patient whilst delivering care. This decision should be based on NHS SOP for Dental Transition to Recovery and current PHE guidance; Table 2 and Table 4.

PPE for dental care

• Social distancing should be maintained at all times as far as reasonably possible in the dental practice in all areas (patient and non-patient facing) and all staff should practise frequent hand washing. This will mitigate against the risks of droplet/contact transmission both between staff/patients and staff/staff.

• For non-clinical areas, such as reception or staff rooms, staff wearing a type IIR fluid-resistant surgical mask may minimise the need to self-isolate under the Test and Trace requirements if someone in the practice subsequently tests positive for Covid-19. Whilst fluid resistant face masks (type IIR) may minimise the risk of transmission of COVID-19 they do not replace appropriate social distancing and frequent hand washing.

• There are some important case studies relating to this on the HEE Y&H site (click this sentence to access).

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Where a member of NHS staff tests positive for coronavirus, the starting point is that the

Test and Trace self-isolation rules apply as anywhere else, and close contacts must self-

isolate if the NHS test and trace service advises them to do so. Close contact excludes

circumstances where full PPE is being worn in accordance with current guidance on

infection, prevention and control (as above).

During periods of widespread community transmission of COVID-19, dental teams should use PPE to treat patients based on the type of dental care they are providing (NHS E & NHS I). Urgent dental care (UDC) falls into two categories depending on whether the treatment includes aerosol generating procedures (AGPs) or not. AGPs should be minimised where possible (NHS E & NHS I).

1. Non-AGP treatment of all patients requires standard infection control procedures. This will ensure there is no contact or droplet transmission of COVID-19. Eye protection, disposable fluid-resistant (Type llR) surgical masks, disposable apron and gloves should be worn.

2. For all AGPs, to prevent aerosol transmission, disposable, fluid-repellent gown, gloves, eye/face protection and an FFP3 respirator should be worn by those undertaking or assisting in the procedure.

NB. FFP3 respirators offer a slightly higher level of protection than FFP2/N95 respirators.

FFP2 and N95 respirators may be used for AGPs if FFP3 respirators are not available

(FFP3/FFP2/N95 applies where FFP3s are referred to throughout this text).

For provision of domiciliary (non-AGP) care in a household setting, disposable plastic

aprons, fluid repellent surgical masks, eye protection and disposable gloves should be worn.

Please see the table below which summarises the guidance on PPE:

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* Fluid-repellent gowns must be worn during aerosol generating procedures (AGPs). If non-fluid-resistant gowns are used, a disposable plastic apron should be worn underneath. **If wearing an FFP3 mask that is not fluid-resistant, a full-face visor must be worn. Operators who are unable to wear a FFP3 mask due to facial hair, religious head coverings or other reasons should wear alternatives such as powered air-purifying respirators (PAPR). ***Eye protection ideally should be disposable. Re-usable eye and face protection (such as polycarbonate safety glasses/goggles) is acceptable if decontaminated between single or single sessional use, according to the manufacturer’s instructions or local infection control policy. Regular prescription glasses are not considered adequate eye protection Please see section below regarding filtering face piece respirators and where clinical staff

have facial hair or fail fit testing

Sessional use of PPE

A session equates to a period of time (no longer than half a day), where a clinical member of staff is within a clinical environment (i.e. within a group of dental surgeries). If a member of staff wishes to go to a non-clinical area, or eat/drink, then the PPE that is being worn on a sessional basis should be doffed (and discarded if single use or decontaminated if reusable). PPE should be disposed of after each session or earlier if damaged, soiled, or uncomfortable. Gloves and aprons are single use with disposal after each patient.

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In the context of dentistry, full sleeve gowns are also considered single use due to risk of contamination of the sleeves after an AGP. All PPE worn for patients that are shielding must be single use. However, where respirators are reusable, covered by a visor and adequately decontaminated, these can be used with a relevant risk assessment. Fluid resistant (type IIR) surgical mask and eye protection can be used for a session of work rather than a single patient or resident contact. Please ensure that masks are not dirty, contaminated, damp and that they are not touched or removed if wearing on a sessional basis. FFP3/FFP2/N95 respirators have a large capacity for the filtration and retention of airborne contaminants. Sessional use can be used in dental practice. A full-face visor changed or decontaminated between patients will protect the respirator from droplet/splatter contamination. Although good practice, there is no evidence to show that discarding disposable respirators, facemasks or eye protection in-between each patient reduces the risk of infection transmission to the health worker or the patient. The rationale for recommending sessional use in certain circumstances is to reduce risk of

inadvertent indirect transmission, as well as to facilitate delivery of efficient clinical care.

It is important that the respirator maintains its fit, function and remains tolerable for the user.

The respirator should be discarded, replaced and NOT be subject to continued use in any of the following circumstances:

• is damaged or distorted

• is obviously contaminated (for example, with respiratory secretions, body fluids)

• is damp

• facial seal is compromised

• is uncomfortable

• is difficult to breathe through

The manufacturers’ guidance should be followed in regard to the maximum duration of use.

Considering the above recommendations that a respirator should be discarded if it becomes obviously contaminated or damp, this may mean that respirators (FFP3s) may be worn once for dental AGPs and then discarded as clinical waste outside of the dental surgery.

Where respirators (FFP3s) are used for a ‘session’ they should be shielded from ‘splatter’ a full face visor to protect the respirator from droplet contamination.

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Reusable gowns

Disposable gowns are recommended as they are easily disposed of at the surgery and require no additional processes. However, where there is a shortage of disposable gowns, reusable gowns may be used. After single patient use, gowns should be transported in a disposable plastic bag. The bag should be disposed of into the household waste. Reusable gowns should be laundered: separately from other household linen; in a load not more than half the machine capacity; and at the maximum temperature the fabric can tolerate, then ironed or tumbled-dried. If a dental nurse runner is used to pass instruments across the threshold of the dental surgery then gloves, apron, eye protection and a surgical mask should be worn as a minimum.

PPE whilst performing decontamination of the dental surgery

When performing decontamination of the dental surgery, a disposable plastic apron and gloves, fluid resistant (type IIR) surgical masks and eye protection should be worn. This should be documented in a risk assessment due to the risk of splashing or coming into contact with bodily fluids (PHE). It is important to note that if an AGP has been performed, then no one should enter the room to carry out decontamination until the surgery has been left vacant for one hour to allow aerosol to settle in a neutral pressure dental surgery.

PHE Poster A visual guide to safe PPE

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Please note:

• Due to the risk of splatter and droplet contamination whilst providing dental care, eye protection must be worn.

• Eye protection, fluid resistant surgical mask, disposable apron and gloves should be worn for all non-AGP dental care.

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What is an aerosol generating procedure (AGP)?

Background: Modes of transmission of COVID-19

Respiratory infections can be transmitted through droplets of different sizes:

• Respiratory droplets which are >5m

• Droplet nuclei which are <5m

Droplet transmission (droplets >5m) occurs when a person is in close contact with someone who has respiratory symptoms (eg. Coughing and sneezing) and can occur via mucosae (mouth and nose) or conjunctiva (eyes) exposed to potentially infective respiratory droplets (WHO). Droplets penetrate the respiratory system to above the alveolar level (PHE). According to current evidence, COVID-19 virus is primarily transmitted through respiratory droplets and contact routes (direct contact with an infected person or indirect contact with contaminated surfaces) (WHO).

COVID-19 virus is expelled as droplets from the respiratory tract of an infected individual (for example during coughing and sneezing) directly onto a mucosal surface or conjunctiva of a susceptible individual(s) or environmental surface(s). Droplets travel only short distances through the air; a distance of at least 2 metres has been used for deploying droplet precautions; however, this distance should be considered as the minimum rather than an absolute. (PHE)

Airborne transmission refers to the transmission of microbes within droplet nuclei (<5m) which can remain in the air for long periods of time and transmitted to others over greater

distances (WHO). Airborne transmission occurs without necessarily having close contact via aerosols (≤5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Aerosols penetrate the respiratory system to

the alveolar level (PHE). Interrupting transmission of COVID-19 requires both droplet and contact precautions. If an aerosol generating procedure (AGP) is being undertaken then airborne precautions are required (PHE). The highest risk of transmission of respiratory viruses is during AGPs of the respiratory tract, and use of enhanced respiratory protective equipment is indicated for health and social care workers performing or assisting in such procedures (PHE)

Within the context of urgent dental care, interrupting transmission of COVID-19 requires contact, droplet and aerosol precautions, depending on the procedures undertaken. (NHS E & NHS I)

Appropriate use of PPE, effective donning and doffing, following IPC and decontamination guidance (including social distancing, hand and respiratory hygiene) are the main mitigating factors to reduce the transmission of COVID19

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What are AGPs in relation to dentistry?

Within the National SOP – Transition to recovery, they list non-AGPs as below:

• Remote consultations

• Oral health assessment

• Preventative and self-care measures delivered in line with Delivering Better Oral Health, non-AGP aspects

• Hand instrumentation/scaling (Appendix 4 – non-AGP periodontal treatment)

• Simple dental extractions

• Caries excavation with hand instruments (Appendix 5 –AMIRD)

• Caries removal with slow speed and high-volume suction (Appendix 5 - AMIRD)

• Placement of restorative material (Appendix 5 - AMIRD)

• Orthodontic treatment

• Removable denture stages (if patient has normal gag reflex)

• Paediatric oral health including stainless steel crowns (Hall crown) and silver diamine fluoride applications (Appendix 6)

Dental AGPs have been described as:

• Use of high-speed handpieces for routine restorative procedures and high-speed surgical handpieces

o Using high-speed drills to open an access cavity or surgical high-speed drills to undertake surgical extraction of a tooth/root will necessitate use of enhanced PPE.

• Use of ultrasonic or other mechanised scalers

• High pressure 3:1 air syringe o To clarify, use of water or air separately in a 3 in 1 is not an AGP.

Joint statement by BSP/FGDP/ODCO regarding dental prophylaxis

The British Society of Periodontology and Implantology, in conjunction with the Office of the CDO and Faculty of General Dental Practice have released a statement on 22.06.2020 regarding dental prophylaxis under Level 4/3 COVID19 alert status. The statement can be found here. The key messages from this document is below:

• A prophylaxis undertaken with a slow speed handpiece, with no water, reduced prophy paste and due diligence, is considered a Non-Aerosol Generating Procedure (Non-AGP) as defined by emergent particle sizes (WHO 2007) and can be safely undertaken with level 2 PPE (R11 mask, gloves, goggles/visor, plastic apron over scrubs).

• However, non-AGP procedures are not without some risk and polishing teeth for cosmetic reasons is not recommended until Level 2 alert status is reached. Prophylaxis does cause splatter which can travel in a ballistic manner between 15-

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120cm from patients’ mouths and which may contact the eyes, mouth and skin of the operator; hence the need for level 2 PPE. Teeth should be dried with gauze and high volume aspiration is recommended.

Medical emergencies and CPR

In the context of a medical emergency within a dental setting, PHE also list ‘manual ventilation’ as an AGP but that chest compressions and defibrillation (as part of resuscitation) are not considered AGPs. PHE and the National Dental SOP both advise that first responders (in any setting) can commence chest compressions and defibrillation without the need for AGP PPE while awaiting the arrival of other clinicians to undertake airway manoeuvres. PHE advise that based on the NERVTAG evidence review and consensus statement, chest compressions will not be added to the list of AGPs. Healthcare organisations may choose to advise their clinical staff to wear FFP3 respirators, gowns, eye protection and gloves when performing chest compressions but it is strongly advised that there is no potential delay in delivering this life saving intervention. Whilst there is widespread transmission of COVID-19 in the community, Table 4 recommends clinicians wear PPE during sessions in all settings. An example protocol and flow for CPR within dental practice can be found here

NERVTAG has also released an evidence review and consensus statement regarding CPR as an AGP, which is found here.

Please see the section PPE for dental care to see the types of PPE required for AGPs and non AGPs

Operators may be concerned at the ‘splatter’ that is created by dental procedures, but this is droplet contamination which universal precautions will guard against.

Risk reduction of droplet contamination can be undertaken by using high-speed suction and use of rubber dam.

Avoid AGPs if possible in treatment. However, where AGPs are necessary, use appropriate PPE and infection control protocols.

Particular care should be taken to avoid surgical extractions at this time. Where it is necessary to remove bone, slow handpieces should be used with irrigation to reduce the risk.

The use of ultrasonic scalers or other pieces of dental equipment powered by air compressor should be avoided at this time and should not be the only reason to wear an

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FFP3 respirator. If, however, they are used as an adjunct to treatment with high-speed drills, staff will already have donned PPE for AGPs.

NB. Prudent use of PPE is vital at times of sustained community transmission for the sake of the whole health and social care economy. Enhanced PPE to use a 3:1 syringe for examination alone should not be deployed. Use of standard infection control measures can be employed by using the irrigation function followed by low pressure air flow from the 3:1 air syringe and all performed with directed high-volume suction.

All those providing dental care must keep up-to-date with the latest evidence and guidance regarding modes of transmission of COVID-19 and PPE. Decisions on PPE worn should be based on current guidance, a local risk assessment and according to the local context.

PHE advise that risk assessment at organisational level requires that organisations consider healthcare-associated COVID-19 risk at local level and according to the local context. Organisational risk assessment and local guidance should not replace or reduce the ability of the health care worker to use appropriate PPE while providing care to patients

Respirator or surgical mask – what is the difference?

Fluid-resistant (Type IIR) surgical masks (FRSMs)

Fluid-resistant (Type IIR) surgical masks (FRSMs) provide barrier protection against respiratory droplets reaching the mucosa of the mouth and nose (PHE). The protective effect of masks against severe acute respiratory syndrome (SARS) and other respiratory viral infections has been well established. There is no evidence that respirators add value over FRSMs for droplet protection when both are used with recommended wider PPE measures in clinical care, except in the context of AGPs (PHE).

Surgical masks should:

• cover both nose and mouth

• not be allowed to dangle around the neck after or between each use

• not be touched once put on

• be changed when they become moist or damaged

• be worn once and then discarded – hand hygiene must be performed after disposal

Filtering face piece respirators (FFP3/FFP2/N95)

All respirators should:

• be well fitted, covering both nose and mouth

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• be specifically fit-tested and fit-checked for the specific make and model (and size if relevant) of the respirator on all staff undertaking AGPs to ensure an adequate seal/fit according to the manufacturers’ guidance

• be fit-checked (according to the manufacturers’ guidance) by staff every time a respirator is donned to ensure an adequate seal has been achieved

• not be allowed to dangle around the neck of the wearer after or between each use

• not be touched once donned

• be compatible with other facial protection used such as protective eyewear so that this does not interfere with the seal of the respiratory protection

• be disposed of and replaced if breathing becomes difficult, the respirator is damaged or distorted, the respirator becomes obviously contaminated by respiratory secretions or other body fluids, or if a proper face fit cannot be maintained

• be removed outside the dental surgery where AGPs have been generated in line with the doffing protocol

• be worn with a full-face visor if a non-fluid resistant respirator is used. (Note that valved respirators are not fully fluid-resistant unless they are also ‘shrouded’)

• cleaned according to manufacturer’s instructions if re-usable FFP3 (filtering 98% of airborne particles) respirators are advised for all AGPs to prevent inhalation of aerosols. This is because FFP3 respirators offer a slightly higher level of protection than FFP2 respirators and advice aims to offer the greatest protection. However, the HSE has stated that FFP2 and N95 respirators (filtering at least 94% and 95% of airborne particles respectively) offer protection against COVID-19 and so may be used if FFP3 respirators are not available. These respirators offer protection against AGPs, are recommended by the World Health Organisation and are used routinely in other countries by dentists for AGPs. All respirators need to be fit tested and checked. Other respirators can be utilised by individuals if they comply with HSE recommendations. Reusable respirators should be cleaned according to the manufacturer’s instructions.

Valved/unvalved respirators

Valved respirators protect the wearer from airborne hazardous contaminants. They are not splash-resistant (unless they have a ‘shrouded valve’ – see below), so they need to be worn with a full-face shield or visor if blood or body fluid splashing is anticipated. The purpose of a respirator’s exhalation valve is to reduce the breathing resistance during exhalation; it does not impact a respirator’s ability to provide respiratory protection. The valve is designed to open during exhalation to allow exhaled air to exit the respirator and

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then close tightly during inhalation, so inhaled air is not permitted to enter the respirator through the valve. Valved respirators protect the wearer from COVID-19 by filtering particles from the inhaled air. However, they may also allow exhaled breath to leave the respirator unfiltered. The breathing rate of people during normal or sedentary work is relatively low. As a result, the valve on a filtering facepiece respirator would not be expected to open very far during exhalation, which would create only a limited path for the larger aerosols expelled by the wearer to navigate. At least some of the wearer-generated aerosols would probably impact on the back of the valve instead of exiting out through the valve opening. When wearing a valved respirator for an AGP, the wearing of a full-face shield or visor in front of it should act as a barrier to minimise the risk of transfer of viral aerosol/droplets from a dental operator (who is asymptomatically carrying the virus) to a patient. Taping over or otherwise covering a respirator valve (e.g. with a surgical mask) is not recommended as it may impact how the respirator functions. For non-AGP procedures, it is preferable to wear a fluid-resistant (type IIR) surgical mask and eye/face protection rather than a valved respirator, to prevent transfer of viral droplet spread from the operator to the patient. Unvalved respirators or a special type of respirator called a ‘shrouded valve’ respirator (which has a raised breathing cage over the valve covered with a special filter medium), can act as both a respirator and as a splash resistant surgical mask. They reduce patient contamination caused by exhaled organisms from health care professionals and protect the wearer from blood and body fluid splashes. References: https://www.6thplanet.com/store/technical/pdf/3m1863_Infection%20Prevention.pdf https://multimedia.3m.com/mws/media/1792732O/respiratory-protection-faq-healthcare.pdf

Choosing a respirator

Please source respirators from a reputable and trusted supplier, and check that they meet the appropriate standards. Useful sites for reading and seeking advice about procuring appropriate PPE: Please click on the Essential Technical Specifications (face masks, gloves, gowns, coveralls, respirators, eye protection) to see what you should be looking for when buying respirators. https://www.gov.uk/government/publications/technical-specifications-for-personal-protective-equipment-ppe If you are unsure of what you are buying, please seek advice from the Health and Safety Executive.

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https://www.hse.gov.uk/respiratory-protective-equipment/index.htm Before purchasing a reusable half mask respirator, please ensure they comply with the HSE recommendations. Reusable respirators should be cleaned according to the manufacturer’s instructions for COVID-19. Please check that they have replaceable P3 particle filters, which are enclosed in a box which can be disinfected. Open/exposed filters cannot be easily cleaned, and are therefore unsuitable for dental practice. HSE and local IPC teams can be contacted if you have questions around decontamination processes.

“The Health and Safety Executive has issued a safety alert about KN95 masks. The warning states that KN95 must not be used as PPE at work as their effectiveness cannot be assured. KN95 is a performance rating under the Chinese standard GB2626:2006, the requirements of which are broadly the same as the European standard BSEN149:2001+A1:2009 for FFP2 facemasks. However, there is no independent certification or assurance of their quality and products manufactured to KN95 rating are declared as compliant by the manufacturer.” There are many counterfeit masks in circulation, and there is guidance about spotting fakes: http://www.bohs.org/wp-content/uploads/2020/05/Spotting-a-Fake-Understanding-FFP-Markings-Branded.pdf https://www.bsif.co.uk/wp-content/uploads/2020/04/CE-Certificate-Checklist-2020-2.pdf

Where clinical staff have facial hair, religious head coverings or have failed fit testing

It is important to ensure that facial hair does not cross the respirator sealing surface and if the respirator has an exhalation valve, hair within the sealed mask area should not impinge upon or contact the valve. Operators who are unable to wear respirators due to facial hair or religious head coverings or other reasons (including repeated failed fit testing) should wear alternatives such as powered air-purifying respirators (PAPR). These deliver clean air through a High Efficiency Particulate Air filter using a fan mounted on the wearer’s belt. Hoods have integral visors. It is not acceptable to use non-fit tested respirator masks as an alternative during AGPs. PHE poster: Facial hair and FFP3 respirators

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Eye and face protection

When providing urgent dental care, eye protection should be worn at all times by both the dentist and assisting dental nurse. This is to provide protection against contamination to the eyes from respiratory droplets, aerosols and splashing of secretions (including respiratory secretions), body fluids, blood and excretions. Eye protection is essential due to the risk of COVID-19 transmission which can occur via conjunctiva (eyes) exposed to potentially infective respiratory droplets.

According to PHE, eye and face protection can be achieved by the use of any one of the following:

• surgical mask with integrated visor

• full face shield or visor

• polycarbonate safety spectacles or equivalent

Facial hair and FFP3 respirators

*Ensure that hair does not cross the respirator sealing surface For any style, hair should not cross or interfere with the respirator sealing surface. If the respirator has an exhalation valve, hair within the sealed mask area should not impinge upon or contact the valve.

*Adapted from The US Centers for Disease Control and Prevention, The National Personal Protective Technology Laboratory (NPPTL),

NIOSH. Facial Hairstyles and Filtering Facepiece Respirators. 2017.

Available online at https://www.cdc.gov/niosh/npptl/RespiratorInfographics.html. Accessed 26/02/2020.

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Regular corrective spectacles are not considered adequate eye protection. Similarly, dental loupes may not provide adequate eye protection and may be challenging to fully decontaminate after use.

While performing AGPs, a full-face shield or visor is recommended in addition to an FFP3 respirator (PHE).

Eye protection should:

• be well fitted

• not be allowed to dangle after or between each use

• not be touched once put on

• be removed and disposed of outside the patient room (dental surgery)

Disposable, single-use, eye protection is recommended (NHS E & NHS I). It can be used for single or single session use and then is to be discarded as clinical waste (PHE). Re-usable eye and face protection (such as polycarbonate safety glasses/goggles or equivalent) is acceptable if decontaminated between single or single sessional use, according to the manufacturer’s instructions or local infection control policy (PHE) (NHS E & NHS I).

If eye and face protection becomes damaged, soiled or uncomfortable, it should be discarded and replaced and not be subject to continued use.

Disposable Gloves Disposable gloves must be worn when providing urgent dental care and decontamination. Disposable gloves are single use only and must be disposed of after each patient contact, followed by hand hygiene. At present, PHE does not recommend ‘double-gloving’ when providing direct patient care.

What is ‘donning’ and ‘doffing’ and how do I do it?

Donning and doffing for AGPs

Donning (putting on) PPE for AGPs:

Ideally, this should be done outside the dental surgery (in a donning area), or if necessary, within the dental surgery (if the surgery is clean, prior to patient entry). A buddy can assist with ‘donning’ of PPE and perform a final visual inspection of the PPE ensemble. The buddy should be trained and competent in the use of PPE.

The dentist and assisting dental nurse should ensure they are ready for the treatment or session ahead. This includes that they are hydrated, the correct size of PPE is available, hair is tied back, and all jewellery removed.

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The current order of donning is as follows:

1. Perform hand hygiene before putting on PPE

2. Long sleeved fluid repellent disposable gown

3. FFP3 Respirator – perform a fit check

4. Eye Protection

5. Gloves

PHE guidance for donning and doffing for AGPs

PHE poster for donning PPE for AGPs

PHE Donning video (incl mask fit check) for AGPs

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Doffing (taking off) PPE following an AGP. PPE should be removed carefully and in a systematic way to avoid contamination. This can be carried out in a dedicated ante room for doffing. If an ante room is available for doffing, the healthcare worker can be supervised by a buddy at a distance of 2 metres. Supervision by a buddy will reduce the risk of the healthcare worker removing PPE and inadvertently contaminating themselves whilst doffing. If there is not a dedicated ante room for doffing, gloves and gown can be removed before leaving the dental surgery in which the AGP was performed (points 1-2). However, eye protection and the FFP3 respirator must always be removed outside of the dental surgery where the AGP was performed (points 3-5). The current order for doffing is as follows:

1. Gloves – ideally remove in doffing area, but can be removed in the dental surgery 2. Gown - ideally remove in doffing area, but can be removed in the dental surgery 3. Eye protection – this must be removed and disposed of outside of the dental surgery 4. Respirator – this must be removed and disposed of outside of the dental surgery 5. Wash hands with soap and water

Please note, PHE states that hand hygiene should be practiced and extended to exposed forearms after removing any element of PPE. Therefore, after removing each element of PPE, that item of PPE should be placed immediately into clinical waste and then hands should be cleaned using an alcohol rub before moving onto the next PPE item to be removed.

PHE guidance on donning and doffing of PPE for AGPs PHE poster on doffing of PPE for AGPs PHE Doffing video for AGPs

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Donning and doffing for non-AGPs

The dentist and assisting dental nurse should ensure they are ready for the treatment or session ahead. This includes that they are hydrated, the correct size of PPE is available, hair is tied back, and all jewellery removed.

The current order of donning PPE for non-AGPs is as follows:

1. Perform hand hygiene before putting on PPE

2. Disposable plastic apron (or long-sleeved fluid repellent gown if splash/splatter expected)

3. Facemask

4. Eye Protection

5. Gloves

PHE guidance for donning and doffing PPE for non-AGPs

PHE poster for donning PPE for non AGPs

PHE video for donning and doffing PPE for non AGPs

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The current order for doffing PPE following non-AGPs: 1. Gloves 2. Disposable apron 3. Eye protection – this must be removed outside of the dental surgery. 4. Fluid resistant (type IIR) surgical mask – this must be removed outside of the dental

surgery. 5. Wash hands with soap and water

Please note, PHE states that hand hygiene should be practiced and extended to exposed forearms after removing any element of PPE. Therefore, after removing each element of PPE, that item of PPE should be placed immediately into clinical waste and then hands should be cleaned using an alcohol rub before moving onto the next PPE item to be removed.

PHE guidance for donning and doffing PPE for non-AGPs PHE poster for doffing PPE for non AGPs PHE video for donning and doffing PPE for non AGPs

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Hand hygiene, what do I need to know? Hand hygiene is essential to reduce the transmission of infection in health and other care settings. As COVID-19 virus is transmitted through contact routes (direct contact with an infected person or indirect contact with contaminated surfaces), hand hygiene is an essential aspect to minimise the risk of COVID-19 transmission and to treat patients safely during a COVID-19 pandemic.

According to PHE and NHS E & NHS I, all staff, patients and visitors should decontaminate their hands with alcohol-based hand rub when entering and leaving areas where patient care is being delivered.

Hand hygiene must be performed immediately before every episode of direct patient care and after any activity or contact that potentially results in hands becoming contaminated, including the removal of any element of PPE, equipment decontamination and waste handling (PHE).

Before performing hand hygiene (PHE):

• expose forearms (bare below the elbows)

• remove all hand and wrist jewellery (a single, plain metal finger ring is permitted but should be removed (or moved up) during hand hygiene)

• ensure finger nails are clean, short and that artificial nails or nail products are not worn

• cover all cuts or abrasions with a waterproof dressing

If wearing an apron rather than a gown (bare below the elbows), and it is known or possible that forearms have been exposed to respiratory secretions (for example cough droplets) or other body fluids, hand washing should be extended to include both forearms. Wash the forearms first and then wash the hands(PHE).

WHO poster – Your 5 moments for hand hygiene

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PHE poster for Best practice: how to hand rub

From: COVID-19. Guidance for infection prevention and control in healthcare settings

Best Practice: how to hand rub

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PHE Poster for Best practice: how to hand wash

From: COVID-19. Guidance for infection prevention and control in healthcare settings

Best Practice: how to hand wash