Infection prevention and control measures include, among other measures: hand hygiene, personal protective equipment and waste management materials.

The Protective equipment consists of garments placed to protect the health care workers or any other persons to get infected. These usually consist of standard precautions: gloves, mask, gown. If it is blood or airborne high infections, will include: Face protection, goggles and mask or face shield, gloves, gown or coverall, head cover, rubber boots. The characteristics of these products will be described in the sections below.

The purpose of personal protective equipment is to reduce employee exposure to hazards when engineering controls and administrative controls are not feasible or effective to reduce these risks to acceptable levels.

PPE is needed when there are hazards present. PPE has the serious limitation that it does not eliminate the hazard at the source and may result in employees being exposed to the hazard if the equipment fails. Any item of PPE imposes a barrier between the wearer/user and the working environment.

This can create additional strains on the wearer; impair their ability to carry out their work and create significant levels of discomfort. Any of these can discourage wearers from using PPE correctly, therefore placing them at risk of injury, ill-health or, under extreme circumstances, death. Good ergonomic design can help to minimize these barriers and can therefore help to ensure safe and healthy working conditions through the correct use of PPE.

Practices of occupational safety and health can use hazard controls and interventions to mitigate workplace hazards, which pose a threat to the safety and quality of life of workers. The hierarchy of hazard controls provides a policy framework which ranks the types of hazard controls in terms of absolute risk reduction.

At the top of the hierarchy are elimination and substitution, which remove the hazard entirely or replace the hazard with a safer alternative. If elimination or substitution measures cannot apply, engineering controls and administrative controls, which seek to design safer mechanisms and coach safer human behavior, are implemented.

Personal protective equipment ranks last on the hierarchy of controls, as the workers are regularly exposed to the hazard, with a barrier of protection. The hierarchy of controls is important in acknowledging that, while personal protective equipment has tremendous utility, it is not the desired mechanism of control in terms of worker safety.

During epidemics/pandemics of highly infectious diseases, such as COVID-19, healthcare workers (HCW) are at greater risk of infection than the general population.  Personal protective equipment (PPE) offers a way of reducing the risk of infection, when treating patients, by minimizing exposure to contaminated body fluids. The recently published Cochrane Review (Verbeek et al, 2020), aimed to evaluate which type of full-body PPE and which method of donning (putting on) or doffing (removing) PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols. For COVID-19, this entails preventing droplets from entering mouth, nose or eyes and preventing them from contaminating the skin elsewhere. Dentists and members of the dental team work in close proximity, usually face-to-face, with patients often for sustained periods of time.

As part of routine care, they are exposed to saliva and blood and carry out aerosol-generating procedures (e.g. use of high-speed air rotors and ultrasonic scalers), making the findings of this review highly relevant to them.

The practice of dentistry involves the use of rotary dental and surgical instruments, such as hand pieces or ultrasonic scalers and air-water syringes. These instruments create a visible spray that can contain particle droplets of water, saliva, blood, microorganisms, and other debris. Surgical masks protect mucous membranes of the mouth and nose from droplet spatter, but they do not provide complete protection against inhalation of airborne infectious agents.

There are currently no data available to assess the risk of SARS-CoV-2 transmission during dental practice. To date in the United States, clusters of healthcare personnel who have tested positive for COVID-19 have been identified in hospital settings and long-term care facilities, but no clusters have yet been reported in dental settings or among DHCP (patients and dental healthcare personnel).

In Hydro Medical Bali the dental service always 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. The DHCP in Hydro Medical Bali should wear a surgical mask, eye protection (goggles, protective eyewear with solid side shields, or a full-face shield), a gown or protective clothing, and gloves during procedures likely to generate splashing or spattering of blood or other body fluids.

During aerosol-generating procedures conducted on patients assumed to be non-contagious, DHCP should use an N95 respirator* or a respirator that offers a higher level of protection such as other disposable filtering face piece respirators, PAPRs, or elastomeric respirators, if available. Respirators should be used in the context of a respiratory protection program, which includes medical evaluations, training, and fit testing. Of note, it is uncertain if respirators with exhalation valves provide source control.

If a respirator is not available for an aerosol-generating procedure, use both a surgical mask and a full-face shield. Ensure that the mask is cleared by the US Food and Drug Administration (FDA) as a surgical mask external icon. Use the highest level of surgical mask pdf icon external icon available. If a surgical mask and a full-face shield are not available, do not perform any aerosol-generating procedures.

We conducted some multiple sequences recommended for donning and doffing PPE in Hydro Medical Bali to make sure everyone is save during the treatment. One suggested sequence for DHCP includes:

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.
3. Gowns and protective clothing should be changed if they become soiled.
4. Put on a surgical mask or respirator.
5. Mask ties should be secured on the crown of the head (top tie) and the base of the neck (bottom tie). If mask has loops, hook them appropriately around your ears.
6. 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.
7. Put on eye protection.
8. Personal eyeglasses and contact lenses are NOT considered adequate eye protection.
9. Perform hand hygiene.
10. Put on clean non-sterile gloves.
11. Gloves should be changed if they become torn or heavily contaminated.
12. 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.
3. Discard disposable gowns after each use.
4. Launder cloth gowns or protective clothing after each use.
5. Exit the patient room or care area.
6. Perform hand hygiene.
7. Remove eye protection.
8. Carefully remove eye protection by grabbing the strap and pulling upwards and away from head. Do not touch the front of the eye protection.
9. Clean and disinfect reusable eye protection according to manufacturer’s reprocessing instructions prior to reuse.
10. Discard disposable eye protection after use.
11. Remove and discard surgical mask or respirator†.
12. Do not touch the front of the respirator or mask.
13. Surgical mask: Carefully untie the mask (or unhook from the ears) and pull it away from the face without touching the front.
14. 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.
15. Perform hand hygiene.

We think in this case Research is urgently required to build evidence on what type(s) of PPE, and which modifications provide most appropriate, manageable protection for members of the dental team in delivering care safely.  This review provides helpful insights on the research required and the importance of registering and coordinating research with comparable outcomes.  First, we urge centers delivering emergency dental care during this pandemic to contribute real life evidence on the setting, staff, patients, care and outcomes. This should include details of the setting, education and training of staff, fit testing, details of PPE used, donning and doffing methods, nature of patient care delivered, and exposure to the virus. Follow-up of staff will further add to the evidence on outcomes.

Second, trials simulating a range of dental care processes and procedures with exposure to harmless viruses, bacteria or chemicals in dental settings considering droplets and aerosols, possibly using mannequins, should be established.  These should be relevant to hospital, primary care and community settings, including domiciliary care.

Third, comparison of PPE for highly infectious patients with standard PPE in simulation exercises will be particularly helpful to determine additional benefits and requirements for different aspects of dental care.  This includes the effect of goggles and face shields which are vital for dental care and for which there are currently no studies with healthcare staff.

We hope these kinds of protection make you feel safe enough to choose Hydro Medical Bali as your option when you need a dental treatment. See you!