2.6. PPE for dental clinicians and the office staff

Dental clinicians should strictly follow the standard precautions for the contact and airborne infections, which include the use of PPE and the hand hygiene protocols. 19 To protect the skin and mucosa against the infected secretions, it is recommended that the operatory room staff wear isolation gowns with surgical gloves, appropriate mask, safety glasses, and face shield prior to entering the operatory room. According to the recommendations of the CDC, the order of wearing PPE includes hand washing, wearing the hospital gown, mask, cap, safety glasses, and surgical gloves. The order of taking off the PPE is the opposite, and hand washing should be performed as the final step. 29

The West China Hospital of Stomatology, Sichuan University has recommended the hand hygiene guideline of two‐before‐and‐three‐after. Accordingly, dental clinicians should wash their hands prior to patient examination, prior to initiation of a dental procedure, after contact with the patient, after touching the nondisinfected equipment and instruments, and after touching the oral mucosa, skin, wounds, blood, body fluids, or other secretions. 10

A hospital gown is an important PPE required when taking care of patients especially if they are suspected for a contagious disease, and is a critical part of many disease control strategies. Hospital gowns can be divided into two main groups for (a) blood‐borne pathogens such as surgical gowns, surgical isolation gowns, and nonsurgical gowns, and (b) for airborne pathogens (coverall gowns and nuclear protective gowns). 30 Thus, it seems that the coverall gowns that protect against airborne pathogens are the best choice for protection against the COVID‐19. 31 The coverall gowns should be disposed after use for each patient.

The standard surgical mask, which is also known as the fluid resistant surgical mask, creates a protective barrier for the nose, mouth, and the respiratory system against splashes, large droplets, and other fluids. It is loose‐fitting and not resistant against smaller airborne particles. The respirators, referred to as N95 masks in the United States and filtering facepiece (FFP) in the United Kingdom, protect the user against smaller airborne particles in aerosol‐generating procedures. 32 The National Health Service guideline recommends the use of FFP‐3 respirators for aerosel generating procedures. FFP‐2 respirators are recommended for level 2 PPE during nonaerosol‐generating procedures. 32 , 33 Moreover, according to the CDC guidelines 34 :

A N95 respirator or a respirator that offers a high level of protection e.g. other disposable filtering facepiece respirators, powered air‐purifying respirator, or elastomeric respirators should be used during aerosol‐generating procedures on patients assumed to be noncontagious.

Respirators should be used as part of a respiratory protection program that includes medical evaluation, training, and fit testing. It should be noted that it is not known whether respirators with exhalation valves provide source control.

If a respirator is not available for use during an aerosol‐generating procedure, both a surgical mask and a full‐face shield should be worn. Make sure that the mask is approved by the US Food and Drug Administration as a surgical mask. Use the highest level of surgical mask available.

Aerosol‐generating procedures should not be performed if a surgical mask and a full‐face shield are not available.

A surgical mask would suffice for the office staff working outside of the operatory room. 35 Ideally, respirators should be changed after visiting each patient. Also, they need to be changed if damaged, or contaminated with blood, respiratory or nasal secretions, or other body fluids. 36 Long‐term use of a mask is only allowed when all patients have the same type of virus, and risk of cross‐contamination is nonexistent. However, this is not the case in a dental office, since some patients may be healthy. Thus, reuse and extended use of a mask are not recommended in a dental office setting. 37

Analysis of conjunctival samples of suspected and definitive cases of COVID‐19 revealed that the routes of transmission are not limited to the respiratory tract only, 38 and COVID‐19 can also be transmitted via contact with the ocular conjunctiva, 39 which can be easily contaminated by droplets. Thus, safety glasses or face shields should be necessarily used during the treatment procedure and cleaned and disinfected between patients.