Among the many issues faced by dentists in 2020, the requirement for personal protective equipment (PPE), including respiratory protective equipment (RPE), to protect against transmission of COVID-19, has been one of the most challenging.
Dentists and members of their teams are often face-to-face with patients for long periods of time, exposed to body fluids and carrying out aerosol-generating procedures (AGPs). A high level of protection from PPE/RPE is therefore required. However, many have struggled to find appropriately fitting RPE and suffered the discomfort of using it during long shifts.
The need for PPE/RPE continues with the third wave of COVID-19, so what are the ongoing challenges and are there any solutions?
PPE/RPE requirements for dentists
- For non-AGPs, Level 2 PPE is needed: disposable gloves, disposable plastic apron, a fluid-resistant surgical mask, and eye/face protection.
- For AGPs, Level 3 PPE is required: disposable gloves, disposable fluid-resistant coverall/gown, filtering face piece (FFP3) mask or hood, and eye/face protection (visors).
While dental teams are familiar with standard PPE, the use of higher levels has been a new, challenging experience for many. They have needed training, including in donning and doffing PPE, as this process itself is a potential cause of contamination. PHE provides guidance on donning and doffing for AGPs as well as non-AGPs.
What are the issues with RPE?
Ongoing debates about the choice of RPE mask
A multitude of RPE types is available. The relative effectiveness, comfort and compliance with different types of masks have been much debated (see Adam Nulty in Dentistry Online).
Tight-fitting FFP2 and FFP3 respirator masks provide the most protection. For FFP2 masks, the maximum permitted inward leakage is 8% and minimum filter efficiency is 94%. FFP3 masks provide an even higher level of protection, with a maximum 2% leakage inwards and minimum filtration efficiency of 99%.
Employers have a responsibility to ensure that RPE is ‘adequate’ to protect the wearer and ‘suitable’ for the individual and the tasks they do.
Face masks must be fit tested, adding to dental practices’ costs
For every tight-fitting mask that an individual wears, a fit test is required. These tests should only be carried out by a competent person, as detailed in HSE guidance.
Fit tests check that there is a good seal between the mask and face, which is essential to protect the wearer. Yet, finding a mask that passes the test can be time-consuming. It is also expensive for the dental practices paying for the tests, especially as the process must be repeated whenever a new type of mask is needed.
Finding a suitable mask that fits is not easy
The problem is there is no ‘one-size-fits-all’ mask, so finding an appropriate fit can mean multiple fit tests. Some people cannot find any mask that passes the test. Common reasons that staff struggle to find a well-fitted mask include:
- Generic-sized masks do not fit an individual’s facial shape.
- Men must be clean-shaven to enable a tight seal. One surgeon in Manchester pioneered the ‘under-mask beard cover’ as a solution for staff unable to shave for personal or religious reasons.
- Medical conditions such as allergies or asthma may limit the RPE options available.
- Dental loupes do not fit over tight-fitting masks.
Alternatives such as powered hoods (powered air purifying respirators – PAPRs) may be recommended for those who cannot use tight-fitting masks. These are more expensive and also require testing before purchase to check there is space for loupes with lights. Although some loupes with external lights do not fit well, new designs of hood may address this problem.
Wearers must perform fit checks and maintenance of RPE
Wearers should use the fit-tested type and size of mask. Each time they use it, they should perform a ‘fit check’ to ensure a tight seal. HSE provides a useful poster and video about how to put on disposable respirators and do a pre-use fit check.
For reusable RPE, ongoing maintenance is needed. Respirators must be decontaminated, and filters replaced according to the manufacturer’s instructions.
It is the user’s responsibility to check and maintain the mask, reporting any problems – incorrect use or poor maintenance may lead to inadequate protection against infection.
Face masks causes skin damage
Many dental staff will attest to the fact that tight-fitting masks are uncomfortable, causing bruising and soreness, especially if worn for long periods.
Experts recommend limiting skin damage by drinking plenty of water to hydrate the skin, using a moisturiser 30 minutes before donning PPE, and applying a liquid barrier film. NHS England advises regular breaks from tight-fitting masks, ideally every hour.
Powered hoods have the benefit of being more comfortable for long-term use but do not suit everyone.
RPE can be cumbersome and claustrophobic
Some dentists find respirators claustrophobic and difficult for communication. This can be exacerbated by hoods that are noisy from the breathing hose. Some find that cumbersome RPE limits the procedures they can perform and causes issues with visual clarity. However, certain models of hood are now designed with highly transparent screens, while those exposing the ears help to reduce noise.
RPE supply is problematic while costs have soared
Especially early during the pandemic, PPE/RPE stock shortages were a much-publicised problem that affected the re-opening of dental practices. NHS providers can now order supplies free from the PPE Portal but especially for private practice, issues may remain.
The escalating cost of PPE also remains a concern, particularly as the introduction of fallow times and other safety measures has reduced income. Many private practices have had to ask patients to pay a supplementary charge to cover the additional PPE.
Sale of counterfeit PPE products has also been reported. Advice is to buy only CE-marked products from a reputable supplier. BDA provides the following guides: How to identify counterfeit PPE and How to spot fake face masks.
Dental professionals worry about future claims related to PPE/RPE issues
Dental teams continue to provide their services through challenging times and some members may be concerned that they could face future complaints or claims because of PPE issues. Welcome news is that the General Dental Council (GDC) has now issued supplementary advice recommending that PPE-related problems should be among the factors considered by decision makers when investigating dental practices.