SPECIAL A R T I C L E
The incidence of puncture in gloves worn during orthodontic clinical practice F. J. T. Burke, MDS, FDS, MGDSRCS (Edin.), H. G. Lewis, LDS, FDS, D. Orth. (RCS Eng), and N. H. F. Wilson, MSc, PhD, DRD, FDSRCS (Edin.) Manchester, England, and Cardiff, Wales
T h e recognition of AIDS as a disease in the United States in 1978 and the subsequent identification of the human immunodeficiency virus--together with the increasing incidence of infections from viruses such as hepatitis B - - h a v e prompted a reappraisal and an increasing awareness of sterilization and cross-infection control procedures in clinical dentistry worldwide, t7 Hands are a major source of cross-infection, 8 since any blood products trapped beneath the fingernails have the potential to infect patients and staff for up to 5 days. 9 Furthermore, cuts and abrasions on the skin may be points of entry for microorganisms in infected blood, which, in patients infected with hepatitis virus, may contain as many as 100 million viruses per milliliter. 2 To help prevent the spread of cross-infection by this route, the routine wearing of gloves during treatment of patients has been advised by many authorities.,0-t2 Orthodontics has not been exempt from the reappraisal of cross-infection control procedures. '3-'6 Although some authorities in the specialty have indicated that they believe orthodontic cross-infection control procedures need not be as rigorous as those for other dental specialties, it has been shown that orthodontists are at considerable risk since, as a group, they have been reported to have the second highest incidence of hepatitis B among dentists.'9 Furthermore, a survey of orthodontists in Georgia 2° indicated that blood was observed in the mouth of patients a mean of 14.9 times per week, with a range of 1 to 150 times. However, Usiskin '8 found that gloves may be snagged against brackets, and Campbell and Phenix t6 found that, while gloves are effective if changed after each patient, they tear easily and are impractical for use with most orthodontic instruments. Since punctures in gloves represent a breach in cross-infection prevention regimens, and it has been estimated that nearly 19,000 bacteria can pass From the Department of Restorative Dentistry, Turner Dental School, Manchester, and Cardiff, Wales. 811118475
Table I. Gloves used in the study
Description [Manufacturer [Countryoforigbz Suretouch vinyl disposable gloves Surgikos Microtouch
Marigold International / LRC Products, London Surgikos, Livingstone, Scotland
Taiwan
United Kingdoal
through a single glove defect in 20 minutes, zt it is considered important to examine the risk and frequency of punctures in gloves worn by orthodontists during clinical practice.
MATERIALS AND METHODS Three dentists in an orthodontic group practice in Cardiff, Wales, were asked to participate in the investigation. Each of these dentists had worn gloves routinely for 3 years and had adopted a single-patient-use pattern of wear in accordance with the guidelines published by many authorities. ",~-'a2-24 Each of the three participating dentists had the same glove size, and each was right-handed. Each undertook a similar clinical workload, with a daily treatment pattern involving orthodontic assessment and fixed and removable appliance therapy. The participating dentists used a total of 750 ambidextrous gloves, 450 bf a vinyl type and 300 of a latex type (Table I), currently marketed for use in clinical dentistry. They were requested to wear the gloves during their normal clinical practice, discarding them after each patient or when there was obvious tearing or puncturing, and to place them into receptacles identifying left (L) and right (R) hand and coded for each individual operator (L, N, and V). One of the dentists had previously experienced an erythematous reaction to latex gloves, and so wore only vinyl gloves. Any gloves that received obvious tears or punctures played no further part in the study. 477
478
Burke, Lewis, and Wilson
Am. J. Orthod. Dentofac. Orthop. May 1991
Table II. Punctures recorded by individual operators Latex
Vinyl Operatorl Code*
h~tact
LL RL LN RN LV RV Total
I
Punctured
Intact
26 16 26 12 6 2 88
85 87 --59 57 288
44 54 79 93 44 48 362
% Punctures
I
Punctured 5 3 -I 3 12
19.6%
4%
Overall punctured
13.3%
*The first letter of the c~le identifies the glove (R, right; L, left), and the second letter indicates the research subject (L, N, or V).
Table III.. Punctures related to left and right gloves Vinyl Code*
Intact
I
Latex
Punctared
Intact
I
Punctured
26 26 6
85 -59
5 -I
87 -57
3 -3
Left glove LL LN LV
44 79 44
Total punctured
64 (17.1%)
Right glove RL RN RV
54 93 48
Total punctured
16 12 2 36 (9.6%)
*The first letter of the code identifies the glove (R, right; L,left) and the second identifies the research subject (L, N, or I0.
The gloves returned to the investigators were tested by being filled with 0.5 L of water at room temperature, and then held in a vertical position for 20 seconds, during which time the presence and position of any leaks were observed and recorded. 25"26 RESULTS The numbers of punctures recorded for each of the three operators, together with the numbers of punctures observed in gloves from right and left hands, are set out in Tables II and III. The distribution of the punctures observed in the used gloves is shown in Fig. 1. As illustrated, most punctures occurred in the left thumb and forefinger, despite the fact that all the clinicians were right-handed. The total number of punctures was 110 (10 of the gloves investigated had more than one puncture). DISCUSSION The water-inflation method used in this study to test the gloves for punctures has been used in previous in-
vestigations. 25'26 However, it has been suggested by Smith and Grant 27 that this technique may result in a failure to record every puncture. They considered that one fourth of the total number of punctures may not be identified when tested by our method, as compared with another method, in which air-filled gloves are immersed in water and emergent air bubbles are monitored for the identification of leaks. However, these methods may not be applied while gloves are being worn, and in this respect a new technique recently proposed by Katz et a1.,28 in which the gloves are immersed in a fluorescein dye during clinical service, may be of value. It should also be noted that, although the test method used in our study may not have revealed all the punctures, a small proportion of the gloves may have contained defects before u s e . 29 Consequently, since our results do not differentiate between punctures that occurred before or after donning, the number of punctures that occurred during treatment may be inflated and may balance the possible underrecording of punctures as a result of the method we adopted. One study of 300 unused gloves,
Special article
Volume 99 Number 5
.fj 7
32
28
479
POSITION OF PUNCTURES
2
2 3
C
17
(Right)
(Left) Fig. 1. Distribution of punctures.
found that fewer than 5% had punctures, 29 while the Clinical Research Associates found that, of the gloves they tested, fewer than 2.5% had manufacturing defects, although some glove types they tested from Taiwan and China had a substantially higher number. 3° The results show variation between operators--as might be expected, given the different operative techniques used by various practitioners. However, closer examination indicates that significantly more of the vinyl gloves failed (88, or 19.6%) when compared with the latex gloves (12, or 4.0%) (X 2 = 36.4, p < 0.001). The fact that one of the operators wore only vinyl gloves was not considered to account for the difference in punctures observed between the latex and vinyl glove types, since the results pertaining to this operator (22% of gloves punctured) were similar to the mean for the other two operators (26% of gloves punctured). Our results with regard to frequency of puncture are similar to those obtained in a study that involved a group of dentists in the restorative field. 26 As in our study, the vinyl gloves used in that investigation were also found to be more susceptible to puncture. When further comparisons are made, however, it may be seen that the numbers of gloves punctured by the restorative dentists who often wore their gloves for more than one patient--are similar to the numbers of punctures in gloves worn by the orthodontists for only one patient. Such comparisons appear to indicate a higher risk of glove puncture among orthodontists. This may be due
to contact with sharp, cut ends of wire, instruments such as wire cutters, and the risk of snagging gloves while trimming acrylic appliances. The results also indicate a higher risk of puncture in gloves worn on the passive hand. More specifically, the thumb and forefinger of the left (passive) hand appear to be areas with the highest risk of puncture (Fig. 1). It was not possible to investigate differences, if any, between the latex and vinyl glove types in terms of in puncture sites because of the small number of punctures in the latex gloves. However, to reduce the risk of puncture, it has previously been shown that, in surgery, two pairs of gloves3~--or even the use of a thimble--will give greater protection, but it would be necessary to balance the increased protection offered by these measures with the possibility of diminished tactile sensation. Nonetheless, for areas of highest puncture risk, it may be justifiable to consider some form of extra protection, especially in the treatment of high-risk cases. Although it has been suggested that orthodontists do not require the same level of cross-infection protection as general dental practitioners, tT'~ all practicing dentists have been advised for more than a decade that precautions must be taken against the spread of hepatitis B infection, 33even though the risk of this infection may be reduced when patients are in a predominantly younger age group, r* Although dental professionals have been considered to be at low risk for AIDS, 35 the consequences of diminished prevention of crossinfection may be serious. Gloves have been shown to
480
Burke, Lewis, attd IVilson
be o f value as a barrier against the spread o f infection, ~6 and while this study has shown that a number o f punctures occur in gloves while they are being worn for orthodontic t r e a t m e n t - - e s p e c i a l l y the vinyl type tested h e r e - - t h e protection afforded by their use is still be~ lieved to be considerable. A further suggestion has been made by Cooley et at., 37 who b e l i e v e that puncture resistance is related to glove thickness. They recommend that orthodontists use gloves with greater palm thickness, since the palm is an area of high stress for ligature placement. To date, .no single type o f nonsterile glove possesses all of the properties that are considered to be ideal, but such factors as good fit are important for the comfort o f the clinician and for the avoidance o f snagging when rotary instruments are used or when appliances are adjusted. For these reasons, it is essential that gloves be available in a large range of sizes, to provide a good fit. 3s Comments have been made with regard to the difficulty orthodontists may experience in carrying out treatment while wearing gloves, t6 Similar problems have been reported in other areas o f d e n t i s t r y - - f o r example, in endodontics. 39 However, dental students ~° and hygienist trainees 41 have not been shown to have reduced expertise while wearing gloves, and Hardison et al. "=2 have demonstrated that the time a group o f qualified dentists takes to perform a standard procedure is not influenced by the wearing of gloves. The time required for a dentist to learn to work effectively while wearing gloves has been estimated to vary between 2 weeks 39 and 2 months ~3 in two separate studies o f general practitioners, and it may be considered that the time required to develop expertise in glove-wearing in orthodontics would differ little from that for general dentistry, since each discipline has its own variety of complex and varied procedures. In this respect, a recent survey o f orthodontists in the United Kingdom has shown that, although one third o f those who participated in the study never wore gloves, approximately 21% wore gloves for every patient, with a further 47% prepared to wear them for specific groups, such as known carriers and high-inoculation-risk patients, or when the physicians had cuts and abrasions on their h a n d s . " CONCLUSION The results o f this study show that, despite the most careful precautions, a certain percentage of gloves will always fail. It also appears that, to date, latex is a more reliable material than vinyl for gloves that are worn to avoid the spread o f infection. W h e n we take into account the fact that the percentages quoted here are for single-patient-use only, and that further use would be likely to increase "the risk of failure, we cannot rec-
Am. J. Orthod. Dentofac. Orthop. May 1991
o m m e n d repeated use o f gloves on the basis o f our experiment. Furthermore, since it appears that a number o f gloves will be punctured in use, it is important that other aspects o f cross-infection control, such as hepatitis B vaccination for those placed at risk and effective sterilization and disinfection procedures, must be emphasized. We thank Mr. P. H. J. Viader and Mr. P. J. Naish, who kindly agreed to participate in this study, and the Department of Medical Illustration, Manchester Royal Infirmary, for producing Fig. 1.
REFERENCES
l. BDA Dental Health and Science Committee Workshop:the problems of cross-infection in dentistry. Br Dent J 1986;160:131-5. 2. Emphasis. Infection control in the dental office; a realistic approach. J Am Dent Assoc 1986;112:459-65. 3. Epstein JB, Mathias RG. Infection control in dental practice: demands of the 1980s. Can Dent Assoc J 1986;52:695-9. 4. Matthews RW, Scully C, Dowell TB.'Altitudes and practices regarding control of cross infection in general dental practice. Health Trends 1989;21:1 i-3. 5. Glenwright HD, Shovehon DS. The prevention of crossinfection: progress in the West Midlands. Br Dent J 1989; 166:125-7. 6. Mitchell R, Russell J. The elimination of cross-infection in dental pmctice--a 5-year follow up. Br Dent J 1989;166:209-II. 7. Yablon P, Spiegel RS, Wolf MC. Changes in dentists' attitudes and behavior concerning infection control practices. Quintessence Int 1989;20:279-84. 8. Sims W. The problem of cross-infection in dental surgery with particular reference to serum hepatitis. J Dent 1980;8:20-6, 9. Allen AL, Organ RJ. Occult blood accumulation under the fingemails: a mechanism for the spread of blood-borne infection. J Am Dent Assoc 1982;105:455-9. 10. Guide to blood-borne viruses and the control of cross infeetibn in dentistry. Br Dent Assoc 1987. I I. Council c,n Dental Materials, Instruments, and Equipment. Council on Dental Practice, Council on Dental Therapeutics. Infection control recommendations for the dental office and the dental laboratory. J Am Dent Assoc 1988;i 16:241-8. 12. Centers for Disease Control. Recommended infection control practices for dentistry. MMWR 1986;35:237-42. 13. Buckthal JE, Mayhew MJ, Kusy RP, Crawford JJ. Survey of sterilization and disinfection procedures. J Clin Orthod 1986; 20:759-65. 14. Kirchhoff ST. Sterilization in orthodontics. Part 1. Sterilization and disinfection. J Clin Orthod 1987;21:326-8. 15. Cash RG. Sterilization and disinfection considerations in office design. J Clin Orthod 1988;22:170-5. 16. Campbell PM, Phenix N. Sterilization in the orthodontic office. J Clin Orthod 1986;20:684-6. 17. Fein S. Infection control in orthodontic practice [Letters to the editor]. AM J ORTHODDENTOFACORTHOP1989;95:84. 18. UsiskinLA. Hand in glove with the orthodontist? [Editorial] Br J Orthod 1989;16:49-50. 19. Starnbach H. Biddle P. A pragmatic approach to asepsis in the orthodontic office. Angle Orthod 1980;50:63-6. 20. Cash RG. Sterilization and disinfection procedures: a survey of Georgia orthodontists. J Clin Orthod 1988;22:22-8.
Volume 99 Number 5 21. Cole WR, Bemard HR. Inadequacies of present methods of surgical skin preparation. Arch Surg 1964;89:215-21. 22. Silverman S. Infectious disease control and the dental office: AIDS and other transmissible diseases, lnt Dent J 1987;37:!0813. 23. Wood PR. The dentist's guide to cross-infection control. [Suppl] The Dentist. Sept. 1987. Guildford, Surrey: Update-Siebert Publications. 24. Crawford JJ. State of the art; practical infection control in dentistry. J Am Dent Assoc 1985;110:629-33. 25. Mitchell R, Cumming CG, MacLennan WD, Ross PW, Peutherer JF, Baxter PMK. The use of operating gloves in dental practice. Br Dent J 1983;154:372-4. 26. Burke FJT, Wilson NHF. The incidence of undiagnosed punctures in non-sterile gloves. Br Dent J (In press). 27. Smith JR, Grant JM. Does wearing two pairs of gloves protect against skin contamination? Br Med J 1988;297:1193. 28. Katz JN, Gobetti JP, Shipman C. Fluorescein dye evaluation of glove integrity. J Am Dent Assoc 1989;118:327-31. 29. Burke FJT, Aldetson JJ, Wilson NHF. The incidence of holes in gloves supplied for routine use in clinical practice. Dent Pract 1988;26:14. 30. Clinical Research Associates. Newsletter 1989;13:1-3. 31. Matta H, Thompson AM, Rainey JB. Does wearing two pairs of gloves protect operating staff from skin contamination? Br Med J 1988;297:597-8. 32. Miles AJG, Wastell C, Allen-Marsh TG. Protection of the left index finger whilst operating on HIV positive patients. Ann R Coil Surg Engl 1989;71:225. 33. Mosley JW, White E. Viral hepatitis as an occupational hazard of dentists. J Am Dent Assoc 1975;90:992-7. "34. ADA Council on Dental Therapeutics. Facts about AIDS. Chicago: American Dental Association, 1987. 35. Klein RS, Phelan JA, Freeman K, et al. Low occupational risk of human immunodeficiency virus infection among dental professionals. N Engl J Med 1988;318:86-90.
Special article
481
36. Gonzalez E, Naleway C. Assessment of the effectiveness of glove use as a barrier technique in the dental operatory. J Am Dent Assoc 1988;117:467-9. 37. Cooley RL, McCourt JW, Bamwell SE. Evaluation of gloves for orthodontic use. J Clin Orthod 1989;23:30-4. 38. Burke FJT, Wilson NHF. Non-sterile glove use: a review. Am J Dent (In press). 39. Rustage KJ, Rothwell PS, Brook IM. Evaluation of a dedicated dental procedure glove for clinical dentistry. Br Dent J 1987;163:193-5. 40. Brantley CF, Heymann HO, Shugars DA, Vann WF. The effect of gloves on psychomotor skills acquisition among dental students. J Dent Educ 1986;50:611-3. 41. Uldricks JM, Caccamo P, Beck FM, Schmakel D. Effect of surgical gloves on preclinical scaling skills. J Dent Educ
1985;49:316-7. 42. Hardison JD, Scarlett MI, Lyon HE, Cooper TM, Mitchell RJ. Gloved and u ngloved: performance time for two dental procedures. J Am Dent Assoc 1988;116:691-4. 43. Clinical research associates. Newsletter 1985;9:1-4. 44. Evans R. Acceptance of recommended cross-infection procedures by orthodontists in the United Kingdom. Br J Orthod 1989;16:189-94.
Reprhzt requests to: Dr. F. J. T. Burke Department of Restorative Dentistry Turner Dental School University o f Manchester Dental Hospital Higher Cambridge Street Manchester M 15 6FH England
The incidence of puncture in gloves worn during orthodontic clinical practice F. J. T. Burke, MDS, FDS, MGDSRCS (Edin.), H. G. Lewis, LDS, FDS, D. Orth. (RCS Eng), and N. H. F. Wilson, MSc, PhD, DRD, FDSRCS (Edin.) Manchester, England, and Cardiff, Wales
T h e recognition of AIDS as a disease in the United States in 1978 and the subsequent identification of the human immunodeficiency virus--together with the increasing incidence of infections from viruses such as hepatitis B - - h a v e prompted a reappraisal and an increasing awareness of sterilization and cross-infection control procedures in clinical dentistry worldwide, t7 Hands are a major source of cross-infection, 8 since any blood products trapped beneath the fingernails have the potential to infect patients and staff for up to 5 days. 9 Furthermore, cuts and abrasions on the skin may be points of entry for microorganisms in infected blood, which, in patients infected with hepatitis virus, may contain as many as 100 million viruses per milliliter. 2 To help prevent the spread of cross-infection by this route, the routine wearing of gloves during treatment of patients has been advised by many authorities.,0-t2 Orthodontics has not been exempt from the reappraisal of cross-infection control procedures. '3-'6 Although some authorities in the specialty have indicated that they believe orthodontic cross-infection control procedures need not be as rigorous as those for other dental specialties, it has been shown that orthodontists are at considerable risk since, as a group, they have been reported to have the second highest incidence of hepatitis B among dentists.'9 Furthermore, a survey of orthodontists in Georgia 2° indicated that blood was observed in the mouth of patients a mean of 14.9 times per week, with a range of 1 to 150 times. However, Usiskin '8 found that gloves may be snagged against brackets, and Campbell and Phenix t6 found that, while gloves are effective if changed after each patient, they tear easily and are impractical for use with most orthodontic instruments. Since punctures in gloves represent a breach in cross-infection prevention regimens, and it has been estimated that nearly 19,000 bacteria can pass From the Department of Restorative Dentistry, Turner Dental School, Manchester, and Cardiff, Wales. 811118475
Table I. Gloves used in the study
Description [Manufacturer [Countryoforigbz Suretouch vinyl disposable gloves Surgikos Microtouch
Marigold International / LRC Products, London Surgikos, Livingstone, Scotland
Taiwan
United Kingdoal
through a single glove defect in 20 minutes, zt it is considered important to examine the risk and frequency of punctures in gloves worn by orthodontists during clinical practice.
MATERIALS AND METHODS Three dentists in an orthodontic group practice in Cardiff, Wales, were asked to participate in the investigation. Each of these dentists had worn gloves routinely for 3 years and had adopted a single-patient-use pattern of wear in accordance with the guidelines published by many authorities. ",~-'a2-24 Each of the three participating dentists had the same glove size, and each was right-handed. Each undertook a similar clinical workload, with a daily treatment pattern involving orthodontic assessment and fixed and removable appliance therapy. The participating dentists used a total of 750 ambidextrous gloves, 450 bf a vinyl type and 300 of a latex type (Table I), currently marketed for use in clinical dentistry. They were requested to wear the gloves during their normal clinical practice, discarding them after each patient or when there was obvious tearing or puncturing, and to place them into receptacles identifying left (L) and right (R) hand and coded for each individual operator (L, N, and V). One of the dentists had previously experienced an erythematous reaction to latex gloves, and so wore only vinyl gloves. Any gloves that received obvious tears or punctures played no further part in the study. 477
478
Burke, Lewis, and Wilson
Am. J. Orthod. Dentofac. Orthop. May 1991
Table II. Punctures recorded by individual operators Latex
Vinyl Operatorl Code*
h~tact
LL RL LN RN LV RV Total
I
Punctured
Intact
26 16 26 12 6 2 88
85 87 --59 57 288
44 54 79 93 44 48 362
% Punctures
I
Punctured 5 3 -I 3 12
19.6%
4%
Overall punctured
13.3%
*The first letter of the c~le identifies the glove (R, right; L, left), and the second letter indicates the research subject (L, N, or V).
Table III.. Punctures related to left and right gloves Vinyl Code*
Intact
I
Latex
Punctared
Intact
I
Punctured
26 26 6
85 -59
5 -I
87 -57
3 -3
Left glove LL LN LV
44 79 44
Total punctured
64 (17.1%)
Right glove RL RN RV
54 93 48
Total punctured
16 12 2 36 (9.6%)
*The first letter of the code identifies the glove (R, right; L,left) and the second identifies the research subject (L, N, or I0.
The gloves returned to the investigators were tested by being filled with 0.5 L of water at room temperature, and then held in a vertical position for 20 seconds, during which time the presence and position of any leaks were observed and recorded. 25"26 RESULTS The numbers of punctures recorded for each of the three operators, together with the numbers of punctures observed in gloves from right and left hands, are set out in Tables II and III. The distribution of the punctures observed in the used gloves is shown in Fig. 1. As illustrated, most punctures occurred in the left thumb and forefinger, despite the fact that all the clinicians were right-handed. The total number of punctures was 110 (10 of the gloves investigated had more than one puncture). DISCUSSION The water-inflation method used in this study to test the gloves for punctures has been used in previous in-
vestigations. 25'26 However, it has been suggested by Smith and Grant 27 that this technique may result in a failure to record every puncture. They considered that one fourth of the total number of punctures may not be identified when tested by our method, as compared with another method, in which air-filled gloves are immersed in water and emergent air bubbles are monitored for the identification of leaks. However, these methods may not be applied while gloves are being worn, and in this respect a new technique recently proposed by Katz et a1.,28 in which the gloves are immersed in a fluorescein dye during clinical service, may be of value. It should also be noted that, although the test method used in our study may not have revealed all the punctures, a small proportion of the gloves may have contained defects before u s e . 29 Consequently, since our results do not differentiate between punctures that occurred before or after donning, the number of punctures that occurred during treatment may be inflated and may balance the possible underrecording of punctures as a result of the method we adopted. One study of 300 unused gloves,
Special article
Volume 99 Number 5
.fj 7
32
28
479
POSITION OF PUNCTURES
2
2 3
C
17
(Right)
(Left) Fig. 1. Distribution of punctures.
found that fewer than 5% had punctures, 29 while the Clinical Research Associates found that, of the gloves they tested, fewer than 2.5% had manufacturing defects, although some glove types they tested from Taiwan and China had a substantially higher number. 3° The results show variation between operators--as might be expected, given the different operative techniques used by various practitioners. However, closer examination indicates that significantly more of the vinyl gloves failed (88, or 19.6%) when compared with the latex gloves (12, or 4.0%) (X 2 = 36.4, p < 0.001). The fact that one of the operators wore only vinyl gloves was not considered to account for the difference in punctures observed between the latex and vinyl glove types, since the results pertaining to this operator (22% of gloves punctured) were similar to the mean for the other two operators (26% of gloves punctured). Our results with regard to frequency of puncture are similar to those obtained in a study that involved a group of dentists in the restorative field. 26 As in our study, the vinyl gloves used in that investigation were also found to be more susceptible to puncture. When further comparisons are made, however, it may be seen that the numbers of gloves punctured by the restorative dentists who often wore their gloves for more than one patient--are similar to the numbers of punctures in gloves worn by the orthodontists for only one patient. Such comparisons appear to indicate a higher risk of glove puncture among orthodontists. This may be due
to contact with sharp, cut ends of wire, instruments such as wire cutters, and the risk of snagging gloves while trimming acrylic appliances. The results also indicate a higher risk of puncture in gloves worn on the passive hand. More specifically, the thumb and forefinger of the left (passive) hand appear to be areas with the highest risk of puncture (Fig. 1). It was not possible to investigate differences, if any, between the latex and vinyl glove types in terms of in puncture sites because of the small number of punctures in the latex gloves. However, to reduce the risk of puncture, it has previously been shown that, in surgery, two pairs of gloves3~--or even the use of a thimble--will give greater protection, but it would be necessary to balance the increased protection offered by these measures with the possibility of diminished tactile sensation. Nonetheless, for areas of highest puncture risk, it may be justifiable to consider some form of extra protection, especially in the treatment of high-risk cases. Although it has been suggested that orthodontists do not require the same level of cross-infection protection as general dental practitioners, tT'~ all practicing dentists have been advised for more than a decade that precautions must be taken against the spread of hepatitis B infection, 33even though the risk of this infection may be reduced when patients are in a predominantly younger age group, r* Although dental professionals have been considered to be at low risk for AIDS, 35 the consequences of diminished prevention of crossinfection may be serious. Gloves have been shown to
480
Burke, Lewis, attd IVilson
be o f value as a barrier against the spread o f infection, ~6 and while this study has shown that a number o f punctures occur in gloves while they are being worn for orthodontic t r e a t m e n t - - e s p e c i a l l y the vinyl type tested h e r e - - t h e protection afforded by their use is still be~ lieved to be considerable. A further suggestion has been made by Cooley et at., 37 who b e l i e v e that puncture resistance is related to glove thickness. They recommend that orthodontists use gloves with greater palm thickness, since the palm is an area of high stress for ligature placement. To date, .no single type o f nonsterile glove possesses all of the properties that are considered to be ideal, but such factors as good fit are important for the comfort o f the clinician and for the avoidance o f snagging when rotary instruments are used or when appliances are adjusted. For these reasons, it is essential that gloves be available in a large range of sizes, to provide a good fit. 3s Comments have been made with regard to the difficulty orthodontists may experience in carrying out treatment while wearing gloves, t6 Similar problems have been reported in other areas o f d e n t i s t r y - - f o r example, in endodontics. 39 However, dental students ~° and hygienist trainees 41 have not been shown to have reduced expertise while wearing gloves, and Hardison et al. "=2 have demonstrated that the time a group o f qualified dentists takes to perform a standard procedure is not influenced by the wearing of gloves. The time required for a dentist to learn to work effectively while wearing gloves has been estimated to vary between 2 weeks 39 and 2 months ~3 in two separate studies o f general practitioners, and it may be considered that the time required to develop expertise in glove-wearing in orthodontics would differ little from that for general dentistry, since each discipline has its own variety of complex and varied procedures. In this respect, a recent survey o f orthodontists in the United Kingdom has shown that, although one third o f those who participated in the study never wore gloves, approximately 21% wore gloves for every patient, with a further 47% prepared to wear them for specific groups, such as known carriers and high-inoculation-risk patients, or when the physicians had cuts and abrasions on their h a n d s . " CONCLUSION The results o f this study show that, despite the most careful precautions, a certain percentage of gloves will always fail. It also appears that, to date, latex is a more reliable material than vinyl for gloves that are worn to avoid the spread o f infection. W h e n we take into account the fact that the percentages quoted here are for single-patient-use only, and that further use would be likely to increase "the risk of failure, we cannot rec-
Am. J. Orthod. Dentofac. Orthop. May 1991
o m m e n d repeated use o f gloves on the basis o f our experiment. Furthermore, since it appears that a number o f gloves will be punctured in use, it is important that other aspects o f cross-infection control, such as hepatitis B vaccination for those placed at risk and effective sterilization and disinfection procedures, must be emphasized. We thank Mr. P. H. J. Viader and Mr. P. J. Naish, who kindly agreed to participate in this study, and the Department of Medical Illustration, Manchester Royal Infirmary, for producing Fig. 1.
REFERENCES
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Reprhzt requests to: Dr. F. J. T. Burke Department of Restorative Dentistry Turner Dental School University o f Manchester Dental Hospital Higher Cambridge Street Manchester M 15 6FH England
