A Periodontist’s Notebook - June 30, 2020
Washing the hands for 60 seconds.
Putting on the first pair of gloves.
Putting on a protective gown.
Putting on a cap.
Putting on a respirator mask.
Putting on goggles and a face shield.
Putting on the second pair of gloves.
Great, the full attire is now on.
First and foremost, the assistant needs to take a picture to upload it on Facebook.
Afterwards, the patient’s treatment may start.
In the recent weeks, we’ve been given international and local authorities’ and literature suggestions (EFP, 2020, Graziani et al. 2020) for assembling clinical combat uniforms that would allow us to work safely while potentially being exposed to a minuscule enemy. One that may not have the ability to pierce through our bulletproof armour, but has shown to has its own, wicked ways to reach the target tissue, the mucosal membranes.
I’m fairly certain, though, that all of us working in the field of Periodontology, bathing daily in aerosols, will agree that the PPE suggestions aren’t that far off from what we’ve been donning thus far in our offices. And judging by the ever-growing number of visual testaments on social media, everybody is now taking an extra mile to ensure safety for their patients, their teams and themselves.
Concurrently with the PPE suggestions, we’ve witnessed more information and attempts at education on handwashing than ever before, aiming mostly at the general public. What a mistake that is. Handwashing is something so basic, so fundamental, almost self-explanatory, but essential, yet it is also us, professionals, that can be so neglectful about it.
Before calling out others, it is only fair to make a painful evaluation of oneself. Have I sometimes forgotten to take off my rings before work? Or felt like I couldn’t be bothered by taking off the delicate bracelet around my wrist, as putting it back on is a real hassle? Growing my nails a bit too long? Shamefully, yes. The flaky skin on my hands, though, serves as a testimony for the methodical regime of handwashing I. Employ. All. The. Time.
As a university teaching faculty member, I am every so often unpleasantly surprised to witness 5th year students not acknowledging the importance of it at all. After taking off their gloves at their previous clinical practice, grabbing something quick for lunch in the cafeteria, touching handrails while running up 3 flights of stairs to our Department, I certainly appreciate their enthusiasm and eagerness to dedicate themselves to their patients, approaching them directly, almost from the doors. However, I cannot help but notice some of them directly putting on gloves, encasing the gunk and microbial communities on their hands in latex or nitrile and deeming it “responsible protection practice”. Students eventually graduate, develop new, fine skills, achieve incredible treatment results, yet rarely look back at something self-understanding as handwashing. And what a long way has this basic practice gone.
The story of a tragic hero
One would think that the practice of handwashing is with us from the dawn of times. However, like many other concepts we take for granted in 2020 (e.g. germ theory of disease, discussed later in text), some have not been employed longer than over a century or even a few decades.
The grounds for antiseptic procedures have initially been set by a brilliant man, a tragic hero whose genius we acknowledge today, yet was, as it too often happens, shunned by his contemporaries. Ignaz Semmelweis was a physician specialised in obstetrics, working at the Obstetrics Clinic at the University Hospital in Vienna, Austria, in the mid 19th century (Manor, Blum, & Lurie, 2016). At the time, Vienna’s hospital had two OB clinics, one that was run by doctors and serving as a teaching unit for students of medicine and another run by midwives. Semmelweis observed that his own, doctor ward had 3 times the incidence of puerperal fever among the mothers (Colebrook, 1956). A disease common at that time, accounting for the maternal mortality of up to 10%, as we know today is caused by a bacterial infection, most commonly by Streptococcus pyogenes. Ironically, at the time, even house birth was safer than giving birth in one of the largest European hospitals.
Bear in mind, medicine was different at that time. Granted, Semmelweis was specialised in obstetrics, but that was a long shot from what medicine and specialties are today, and I deem this is becoming a reality for dentistry as well. As Atul Gawande, a contemporary, great medical mind says, today “Everyone just has a piece of the care” (TED, 2012). In Semmelweis’ times though, one would start their day with autopsies, only to move on to a living body, delivering a baby. In an unexpected turn of events, Semmelweis’ good friend and fellow physician, Jakob Kolletscka, died of sepsis after a minor injury of his finger sustained during an autopsy. Given that his post-mortem analysis showed pathological findings identical to the ones of the deceased women, Semmelweis came with a hypothesis that the disease comes from something, an agent, that can be found in the flesh of the cadavers. While in 1847 he could not name this agent, it was still years before Louis Pasteur’s demonstration of bacteria as the cause of putrefaction (1956), and decades before John Lister proved and confirmed transmission of bacterial infections by the hands of doctors (1867), or Robert Koch’s proposition of the germ theory of disease and his postulates (1890) (Cavaillon & Chrétien, 2019).
What does all of this have to do with handwashing? Well, Ignaz Semmelweis introduced the practice of handwashing and disinfection with chlorinated lime solution. As an outcome of one of the most incredible (and among the first!) large-scale intervention trials in the history of medicine, the incidence of puerperal fever mortality dropped under 1.5% within a year.
As it often happens when a dogma is questioned (scandalously, against its definition!) and novelties are introduced, even when backed with tangible evidence, there’s a rise of resistance. In Ignaz Semmelweis’ case, this meant backs were turned against him, and he ended his short-lived life at the age of 47 in a mental institution (Loudon, 2000). The legacy he left, however, can be observed in the most basic principle of modern medical and dental practice.
All (sc)rubbed up
Gloves were first introduced in medicine in 1889 and have become a standard unimaginable not to abide to. Wearing gloves, though, does not mean handwashing could or should be omitted, by any means!
Medicine takes handwashing to a higher level, even terminology-wise. While scrubs are defined as antisepsis with running water and an aqueous solution containing active ingredients (CHX, povidone-iodine, etc.), rubs are presuming the use of an alcohol solution. If used according to instructions, they decrease the numbers of colonising bacteria and prevent surgical site infection; however, the data is inconclusive when it comes to highlighting the superiority of a particular method (Tanner, Dumville, Norman, & Fortnam, 2016).
With regards to handwashing practices in the current period, a plain old soap will suffice to destroy the bilipid viral layer, just as does the use of alcohol-based rubs (Kratzel et al., 2020).
The only trick? Think about it - are you doing it often-, long- and properly-enough?
All gloved up
Daily we put on and doff gloves numerous times, without questioning their ability to protect us and provide a barrier against bodily fluids and chemicals. They are, however, not without limitations. Or holes.
In the year 2006, the American Food and Drug Administration (FDA) issued a ruling on the standards for surgical and patient examination gloves, lowering the acceptable defect rate in a produced lot to 1,5% and 2,5%, respectively. Of course, these decisions were driven by numbers and economic reasoning. In particular, a reduced rate of blood-borne illnesses contagion could be expected with this lower defect rate, approx. 0,6 cases of HIV and hepatitis B and C, but also 100 000 blood screening tests less performed within a year (FDA, 2006).
But even if there’s no defect in the gloves we wear (though do check, before you put them on), gloves develop microporosities during use. Let us not be selfish and think of only protecting ourselves – while microporosities may allow the transfer of microorganisms from the outside to the inside, this may also happen the other way around, by the transfer from the practitioners’ skin to the surface of the glove itself (Jamal & Wilkinson, 2003). Moist and warm conditions inside the glove favour bacterial growth, with bacterial counts increasing with time. This occurs even despite preoperative hand disinfection, as viable bacteria will persist in nooks and crannies of the skin and hair follicles (Wistrand, Söderquist, Falk-Brynhildsen, & Nilsson, 2018).
Double gloving is also suggested as one of the PPE practices during these times. Generally speaking, more evidence is needed to draw firm conclusions on this practice. A 2016 Cochrane systematic review highlights that the addition of a second pair of surgical gloves significantly reduces perforations to the innermost pair of gloves. Glove penetration is, in case of the current viral agent, not a concern, due to its route of transmission through droplets; as of now, there is no data on transmission by blood. However, the practice of double gloving may provide some benefits in terms of doffing only the second pair and changing to a new pair with each new patient, leaving the innermost glove technically unexposed to the virus (Graziani et al. 2020).
Human psychology entering the game
Us humans are prone to cognitive biases, defined as “systematic patterns of deviation from norm or rationality in judgment”. One in the long list of biases is a so-called response bias, a tendency to respond inaccurately or falsely to questions. Researchers are well aware of this bias in studies that involve self-reporting questionnaires, as, let’s be honest, we are all prone to painting a better picture to some extent when presenting ourselves to the outside.
Let’s engage in a short thought experiment. If I asked you a simple question: how often and how long do you wash your hands, what would be the answer? Without a doubt, what I would get is most probably an over-estimation of the real situation. In fact, there’s even research supporting this, highlighting over-reporting of handwashing among the medical professionals (Contzen, De Pasquale, & Mosler, 2015). Part of this is due to socially desirable responding. We all know we should be handwashing often and adequately, we know our colleagues know this as well; thus we report a better version of our reality.
Being aware of the bias, allow yourself for some self-observation and re-answer the question above. Like any other practice, hand hygiene can be improved (Kitsanapun & Yamarat, 2019) through continuous education and training: the general public, our co-workers, students, ourselves.
Lessons re-learned
If we go back to the story of Ignaz Semmelweis, we need to acknowledge that it is indeed a tragic one, one of many in the history of humankind, past and future. Out of his personal and professional tragedy, something good was eventually born. So, while I do not advise us to bat a blind eye to the negativity that is (still) our daily life, I vow to find positivity as well. This pandemic has reminded and re-taught us of practices we’ve maybe been neglectful, or at least too relaxed about. Why not use this chance to improve? Really, who of us wouldn’t jump to seize an opportunity of becoming better, raise your hand?
Literature and suggested reads:
Cavaillon, J. M., & Chrétien, F. (2019). From septicemia to sepsis 3.0—from Ignaz Semmelweis to Louis Pasteur. Genes and Immunity, 20(5), 371–382. https://www.nature.com/articles/s41435-019-0063-2
Colebrook, L. (1956). The story of puerperal fever—1800 to 1950. Obstetrical and Gynecological Survey, 11(4), 513–515. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978745/
EFP. (2020). EFP suggestions for the management of a dental clinic during the Covid-19 pandemic. Retrieved May 30, 2020, from https://www.efp.org/publications/covid-19.html
FDA. (2006). Medical Devices; Patient Examination and Surgeons’ Gloves; Test Procedures and Acceptance Criteria. Final Rule. Federal Register, 71(243), 75865–79. https://pubmed.ncbi.nlm.nih.gov/17294550/
Graziani, G., Izzetti, R., Lardani, l., Biancarini, M.L., Gabriele, M., editors. (2020). Dental practice in the era of SARS-CoV-2 pandemic: a checklist to enhance safety and good practice. Bologna, Italy: Edizioni Martina. https://www.edizionimartina.com/edizionimartina/dettaglitesti/651.asp
Jamal, A., & Wilkinson, S. (2003). The mechanical and microbiological integrity of surgical gloves. ANZ Journal of Surgery, 73(3), 140–143. https://pubmed.ncbi.nlm.nih.gov/12608978/
Kratzel, A., Todt, D., V’kovski, P., Steiner, S., Gultom, M., Thao, T. T. N., … Pfaender, S. (2020). Inactivation of Severe Acute Respiratory Syndrome Coronavirus 2 by WHO-Recommended Hand Rub Formulations and Alcohols. Emerging Infectious Diseases, 26(7). https://pubmed.ncbi.nlm.nih.gov/32284092/
Loudon, I. (2000). The Tragedy of Childbed Fever. Oxford, UK: Oxford University Press. https://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780198204992.001.0001/acprof-9780198204992
Manor, J., Blum, N., & Lurie, Y. (2016). “No Good Deed Goes Unpunished”: Ignaz Semmelweis and the Story of Puerperal Fever. Infection Control and Hospital Epidemiology, 37(8), 881–887. https://pubmed.ncbi.nlm.nih.gov/27181742/
Tanner, J., Dumville, J. C., Norman, G., & Fortnam, M. (2016). Surgical hand antisepsis to reduce surgical site infection. Cochrane Database of Systematic Reviews, 2016(1). https://pubmed.ncbi.nlm.nih.gov/26799160/
TED. (2012). How do we heal medicine? Retrieved May 30, 2020, from https://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine/transcript#t-546795
Wistrand, C., Söderquist, B., Falk-Brynhildsen, K., & Nilsson, U. (2018). Exploring bacterial growth and recolonisation after preoperative hand disinfection and surgery between operating room nurses and non-health care workers: A pilot study. BMC Infectious Diseases, 18(1), 1–8. https://pubmed.ncbi.nlm.nih.gov/30223772/
Nuland, S.B. (1988). Doctors. New York, USA: Knopf. https://www.penguinrandomhouse.com/books/122994/doctors-by-dr-sherwin-b-nuland/
Contzen, N., De Pasquale, S., & Mosler, H. J. (2015). Over-reporting in handwashing self-reports: Potential explanatory factors and alternative measurements. PLoS ONE, 10(8), 1–22. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547747/
Kitsanapun, A., & Yamarat, K. (2019). Evaluating the effectiveness of the “germ-free hands” intervention for improving the hand hygiene practices of public health students. Journal of Multidisciplinary Healthcare, 12, 533–541. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628857/