Factors influencing the wearing of protective gloves in orthodontic practice.

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(1)09_EJO27_1_cjh074_Cheng_D3. 10/2/05 8:58 AM. Page 64. European Journal of Orthodontics 27 (2005) 64–71 doi: 10.1093/ejo/cjh074. European Journal of Orthodontics vol. 27 no. 1  European Orthodontic Society 2005; all rights reserved.. Factors influencing the wearing of protective gloves in orthodontic practice Hsin-Chung Cheng, Sheng-Yang Lee and Hung-Yi Chou Department of Dentistry, Taipei Medical University Hospital, Graduate Institute of Oral Rehabilitation, School of Public Health, Taipei Medical University, Taiwan. The purpose of this study was to explore how wearing, or not wearing, protective gloves affects the efficiency of orthodontists in performing certain orthodontic procedures. Thirty-six volunteers were randomly selected from members of the Taiwan Association of Orthodontists. A visual analogue scale (VAS) was used to determine the degree of convenience subjects felt in performing 11 specified orthodontic procedures, with and without gloves. In addition, the time required to bend round and rectangular archwires and to tie and untie ligature wires was recorded. The results showed that for 10 of the 11 orthodontic tasks there was perceived to be no difference when wearing, or not wearing, gloves. Only when bending a round archwire was there perceived to be a difference. When the four orthodontic procedures were undertaken on a typodont and timed, no significant difference was found between the use of gloves/no gloves. SUMMARY. Introduction Since the early 20th century, wearing protective gloves during surgical operations has been highly valued in the medical society (Burke and Wilson, 1989). In the past, dentists wore gloves only when performing oral surgery. However, by 1974 the routine use of gloves was being discussed (Crawford et al., 1974). Following reports of several hepatitis B cross-infections in the USA (Rimland et al., 1977; Shaw et al., 1986; Centers for Disease Control, 1993), the American Dental Association (1978) released the ‘Infection Control Recommendations’ and formally recommended that dentists should wear gloves in practice to avoid any possible contact with a patient’s saliva or blood. The Centers for Disease Control (1987) actively promoted barrier techniques and universal precautions, and the American Occupational Safety and Health Administration (1991) began to implement dental infection control measures. Since that time, the wearing of protective gloves has become mandatory for dentists in practice and is an important infection control procedure. Among dental practitioners, however, fewer orthodontists were found to wear gloves compared with other general dental practitioners (GDPs). Woo et al. (1992) investigated orthodontists and other GDPs in California and found routine wearing of gloves in 59 and 97 per cent, respectively. McCarthy et al. (1997) compared orthodontists in Canada with other GDPs and found percentages of 85 and 92, respectively. Slightly lower figures were found in a British study, where Burke et al. (1992) reported glove wear in 39 per cent of orthodontists and 88 per cent of GDPs, while the figures for a Taiwanese population were 51 and 69 per cent, respectively (Cheng et al., 1997).. In Taiwan, only in the last 10 years has infection control in dentistry been valued and promoted. Prior to this, few orthodontists wore gloves, as it was perceived that gloves affected the sense of touch, limited finger movements, and affected the efficiency of some delicate operations such as wire bending and tying ligatures (Starnbach and Biddle, 1980; Cooley et al., 1989; Evans, 1989; Davis and BeGole, 1998). In addition, gloves are easily penetrated by wires, or may become tangled with instruments or wires, which was thought to cause inconvenience (Burke et al., 1992; Woo et al., 1992). A review of the literature showed limited data on how wearing gloves affects dental efficiency or manual dexterity. Uldricks et al. (1985) reported that wearing gloves did not affect the scaling technique of dental hygiene students and Wilson (1986) noted that the dexterity of dental hygienists when using dental probes was not affected by gloves. Brantley et al. (1986) found that the wearing of gloves by dental hygiene students in the laboratory did not affect the time taken to restore a tooth and Hardison et al. (1988) detected no significant difference between dentists wearing and not wearing gloves when preparing canals and placing a pin. It therefore appears that wearing gloves does not affect the efficiency of the majority of dental procedures. However, research in this area of orthodontics has rarely been undertaken. Therefore, the purpose of this study was to explore how wearing gloves may affect the performance of orthodontic procedures. The results would then serve as a reference for promoting infection control..

(2) 09_EJO27_1_cjh074_Cheng_D3. 10/2/05 8:58 AM. Page 65. 65. P ROT E C T I V E G L OV E S I N O RT H O D O N T I C P R AC T I C E. Materials and methods Study subjects. Questionnaire survey. Thirty-six subjects were randomly selected from members of the Taiwan Association of Orthodontists. Following their agreement to participate, a questionnaire survey and operational assessment was conducted on each subject.. The questions assessed the subjects’ perceptions of their efficiency when conducting 11 orthodontic procedures while wearing or not wearing gloves. The questionnaire (Table 1) included a total of nine questions relating to their level of experience and background; seven to their. Table 1. Questionnaire. A. 1. 2. 3. 4. 5. 6.. Background data Age: ➀ ≤30 ➁ 31–41 ➂ 41–50 Gender: ➀ Male ➁ Female Practice years: ➀ ≤5 ➁ 6–10 ➂ 11–15 Practice place: ➀ Hospital ➁ Dental office ➂Other Practice type: ➀ Solo practice ➁ Group practice Practice distribution: ➀ Only orthodontic practice ➁ 70 per cent orthodontic practice + 30 per cent general dental practice ➂ 50 per cent orthodontic practice + 50 per cent general dental practice ➃ 30 per cent orthodontic practice + 70 per cent general dental practice ➄ Other 7. Patient numbers/day: ➀ 0–10 ➁ 11–20 ➂ 21–30 8. Practice days/week: ➀ 1 ➁2 ➂3 ➃4 9. Main age distribution of orthodontic patients: ➀ ≤14 ➁ 15–19. ➃ ≥50 ➃ ≥16. ➃ ≥30 ➄5 ➂ 20–60. ➅6 ➃ ≥60. B. 1. 2. 3. 4.. ➆7. Perception of gloves on orthodontic practices Wearing gloves during orthodontic training: ➀ For all patients ➁ For none ➂ For selected patients Wearing gloves in current orthodontic practice: ➀ For all patients ➁ For none ➂ For selected patients Frequency (patient no.) of changing gloves: ➀1 ➁2 ➂3 ➃4 ➄ ≥5 ➅ No change Not wearing gloves in performing orthodontic tasks: ➀ Wire bending ➁ Ligature ➂ Activation ➃ Try bands ➄ Bonding and banding ➅ Debonding and debanding 5. Main obstacle of wearing gloves in performing orthodontic tasks: ➀ Decrease in finger dexterity ➁ Decrease in operation efficiency ➂ Increase in cost ➃ Increase in waste ➄ Increase in uncomfortable sensation on hand ➅ Increase in hand hypersensitivity ➆ No effect 6. Main affecting factor of gloves on performing orthodontic tasks: ➀ Size ➁ Fit ➂ Powders ➃ Thickness ➄ Material ➅ Other 7. Chances of sharps injury to hands during glove wearing: ➀ Increase ➁ Decrease ➂ No effect. C. Convenience of orthodontic tasks when wearing and not wearing gloves I. Wearing gloves 1. Trying bands 2. Using prophylaxis 3. Bonding 4. Bending a round wire 5. Bending a rectangular wire 6. Bending a closed loop 7. Tying a ligature 8. Untying a ligature 9. Changing a power chain 10. Activating a closed loop 11. Adjusting a retainer. Very poor convenience Excellent convenience ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ———————————————————————————————————. II. Not wearing gloves 1. Trying bands 2. Using prophylaxis. Very poor convenience Excellent convenience ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ——————————————————————————————————— ———————————————————————————————————. 3. 4. 5. 6. 7. 8. 9. 10. 11.. Bonding Bending a round wire Bending a rectangular wire Bending a closed loop Tying a ligature Untying a ligature Changing a power chain Activating a closed loop Adjusting a retainer.

(3) 09_EJO27_1_cjh074_Cheng_D3. 10/2/05 8:58 AM. Page 66. 66 perception of how wearing gloves might affect the performance of each task; and 11 to self-assessment of the convenience of performing the 11 orthodontic tasks when wearing and not wearing gloves. The convenience of each task was recorded using a 10 cm visual analogue scale (VAS) with 0 cm representing ‘very poor convenience’ and 10 cm ‘excellent convenience’ (Price et al., 1983). The subjects marked the perceived convenience for each task directly on the VAS and the data were then converted to percentages, which constituted the so-called ‘efficiency score’. The perceived efficiency score when undertaking the tasks without wearing gloves was labelled ‘a’, and while wearing gloves ‘b’. Therefore, the difference between a and b represents the efficiency difference between wearing and not wearing gloves.. H-C CHENG ET AL.. Inc., Cary, North Carolina, USA). The Wilcoxon rank sum test was used to compare each subject’s response to the questions and also the time required for the exercises with and without gloves. The Kruskal–Wallis test was used to examine the differences with and without gloves relative to the level of experience of the orthodontist.. Results Participants The 36 subjects were randomly selected from members of the Taiwan Association of Orthodontists. The characteristics of these participants are shown in Table 2. Perception of gloves on orthodontic practices. Performance assessment The subjects were also asked to perform four orthodontic procedures: bending round and rectangular archwires, and tying and untying ligatures, while wearing and not wearing gloves. The time taken was recorded with a stopwatch. Each exercise involved the subject using a new pair of powder-free latex gloves (examination latex gloves, Sempermed, Hatyai Songkhla, Thailand). In the first exercise, the subjects bent a round wire (0.016 inch, UT-211-160, Tomy, Tokyo, Japan) with light bird beak pliers (60-315c, Tomy) until the wire conformed to the arch form on a cardboard template. The second exercise involved bending a pre-formed rectangular arch wire (0.016 × 0.022 inch, UT-300-934, Tomy) with light bird beak pliers until it conformed to the closed loop arch form shown on the template. The third exercise used a Mathieu needle holder (60-215, Tomy) to tie a 0.010 inch ligature wire to brackets placed on the four upper incisors of a typodont and then to use a ligature cutter (60-605, Tomy) to remove the excess wire and a ligature director (YDM-22-704, Tomy) to turn the end of the ligature inwards. Finally, the subjects were asked to use a ligature cutter (SD-60-150S, Tomy) to remove the ligature. The exercises were then repeated without the use of gloves and timed in an identical manner. The time difference was obtained by subtracting the time spent by the subjects on each exercise without wearing gloves from that when wearing gloves. If the result was positive, it meant that more time was required to perform the task without wearing gloves and if it was negative, it meant that more time was required to perform the task when wearing gloves. Data analysis All statistical tests were carried out using the SAS Statistical Software Package version 6.12 (SAS Institute. The main reasons reported for not wearing gloves in orthodontic practice were: loss of manual dexterity (27.8 per cent) and reduced efficiency (16.7 per cent). However, it was of interest that 41.7 per cent of participants considered there to be no difference between wearing and not wearing gloves. Almost 39 per cent of orthodontists did not wear gloves for bending wire and 11.1 per cent placed bonds without wearing gloves. Seventy-five per cent of subjects considered the size of the gloves to be the main factor affecting performance, Table 2. Characteristics of the study participants (n = 36).. Items. Number. Percentage. Gender Male Female. 22 14. 61.1 38.9. Age ≤30 31–40 41–50 ≥50. 1 22 11 2. 2.8 61.1 30.6 5.6. Practice years ≤5 6–10 11–15 ≥16. 5 17 9 5. 13.9 47.2 25.0 13.9. Practice location Hospital Local office. 14 22. 38.9 61.1. Use of gloves in past orthodontic training All patients None Selected patients. 16 7 13. 44.4 19.4 36.1. Use of gloves in current practice All patients None Selected. 26 4 6. 72.2 11.1 16.7.

(4) 09_EJO27_1_cjh074_Cheng_D3. 10/2/05 8:58 AM. Page 67. 67. P ROT E C T I V E G L OV E S I N O RT H O D O N T I C P R AC T I C E. Figure 1 Efficiency score and efficiency differences when wearing and not wearing gloves for 11 orthodontic tasks.. while 38.9 per cent believed that the odds of receiving a sharps injury were reduced by wearing gloves. Performing orthodontic tasks with and without gloves Figure 1 shows that of the 11 orthodontic procedures rated, the lowest convenience index when wearing gloves was for bending a round archwire (40.47 per cent). In contrast, the highest convenience index for not wearing gloves was for the same procedure (69.38 per cent). This difference was significant (P < 0.001). For the other 10 orthodontic procedures, although the convenience index of not wearing gloves was generally higher than that when wearing gloves, there were no significant differences between the values. Thus, the wearing of gloves had a minimal influence on the perceived efficiency or convenience of performing the orthodontic tasks. Orthodontic background of wearing or not wearing gloves The subjects were divided into different groups based on their age, gender, years in practice, whether they had worn gloves during training, and whether they wore gloves in their current practice. For several of the 11 procedures there was a significant difference (P < 0.05) in terms of perceived convenience between wearing and not wearing gloves for those who were over 41 years of age when compared with the subjects below 40 years of age (Figure 2). Figure 3 shows that there was also a significant difference (P < 0.05) for two of the procedures between those who had been in practice for. more than 11 years and the remaining subjects. The results (Figure 4) indicate that, for the majority of the orthodontic procedures, those who wore gloves during their training perceived fewer problems than those who did not wear gloves at all, or who wore them selectively, during training. For those clinicians who wore gloves for all current practices, the perceived convenience was higher for one of the 11 procedures (bending a round archwire; Figure 5) when compared with those who did not use gloves routinely. Performance time for orthodontic tasks when wearing or not wearing gloves The time required to bend round and rectangular wires and to ligate them was reduced when wearing gloves. However, there were no significant differences between the times spent on these tasks (Figure 6). In addition, the time taken was not influenced by the level of experience of the orthodontist. Discussion As most orthodontic treatment is non-invasive, the use of barrier techniques for infection control was overlooked for some time. However, there are various procedures during orthodontic treatment, from simple oral cleaning prophylaxis to complicated wire bending, and it is not unreasonable to assume that the use of gloves may have a different impact on these various treatment procedures. The unwillingness of orthodontists to wear gloves in the past was probably because they had trained at a time when the routine use of.

(5) 09_EJO27_1_cjh074_Cheng_D3. 10/2/05 8:58 AM. Page 68. 68. H-C CHENG ET AL.. Figure 2. Efficiency difference between not wearing and wearing gloves in performing orthodontic tasks by age.. Figure 3. Efficiency difference between not wearing and wearing gloves in performing orthodontic tasks by the number of years in practice.. gloves was not commonplace. Therefore, this study allowed orthodontists to subjectively evaluate the convenience and impact of using gloves for 11 routine orthodontic tasks. The study also asked subjects to carry out four routine orthodontic procedures on a typodont, with and without gloves, and the time taken to complete the tasks was recorded. It was assumed that ‘the longer the performance time, the worse the efficiency’.. The main reasons stated for not wearing gloves were similar to those in other studies (Burke et al., 1992; Woo et al., 1992; McCarthy et al., 1997). According to the convenience assessment of the 11 treatment procedures in this study, wearing gloves tended to be perceived as being less convenient than not wearing gloves. However, the differences were not significant, except for bending a round archwire (P < 0.001)..

(6) 09_EJO27_1_cjh074_Cheng_D3. 10/2/05 8:58 AM. Page 69. P ROT E C T I V E G L OV E S I N O RT H O D O N T I C P R AC T I C E. 69. Figure 4 Efficiency difference between not wearing and wearing gloves in performing orthodontic tasks by whether orthodontists had used gloves during training.. Figure 5 Efficiency difference between not wearing and wearing gloves in performing orthodontic tasks by whether orthodontists use gloves in their current practice..

(7) 09_EJO27_1_cjh074_Cheng_D3. 10/2/05 8:58 AM. Page 70. 70. H-C CHENG ET AL.. Figure 6 Performance time when wearing or not wearing gloves for different orthodontic tasks and the effects of orthodontic background.. Therefore, it appears that most orthodontists do not feel that there is a major difference between wearing and not wearing gloves. Orthodontists who were younger (40 years of age or less), female, had fewer years in practice (5 years or fewer), had worn gloves throughout training, and wore gloves routinely in current practice, generally perceived more convenience in performing the orthodontic tasks while wearing gloves compared with not wearing them. Only for bending a round archwire was this felt not to be the case. This is probably because orthodontists are aware that the resistance of the gloves hampers the dexterity of the thumb and forefinger when bending the round wire into an arch form. From past clinical experience, bending a round wire with gloves may be made easier by wrapping the round wire with gauze while bending it into an arch, or soaking the fingertip areas of the gloves in water to lubricate them. The study showed that older orthodontists and those with more years in practice felt more inconvenienced when wearing gloves. In addition, male orthodontists perceived more inconvenience than females. Although little documentation is found related to these issues, the outcomes of this investigation were consistent with previous studies. For example, Burke and Wilson (1991) found that of those GDPs who did not wear gloves, 91 per cent had more than 10 years’ experience in practice, and males wore gloves less frequently than females (65 versus 77 per cent). Previous research (Cheng et al., 1995) has also shown that older practitioners and those with more years in practice tend to wear gloves less frequently, and again, with male dental. practitioners wearing gloves less often than females (64.5 versus 85.5 per cent). After objectively recording the time required to complete the four orthodontic tasks on a typodont, the time for three of the four procedures was less when wearing gloves than when not wearing gloves, although this only reached borderline significance (0.05 < P < 0.1). Although some subjects undoubtedly found it inconvenient to bend wire while wearing gloves, the results refute the prejudice that wearing gloves increases operation time. Of all the orthodontic tasks, regardless of whether or not gloves were being worn, bending a rectangular wire into a closed loop was the most time-consuming and complicated procedure. The findings of this study suggest that although the time spent performing the four orthodontic tasks with or without gloves was not affected by the different backgrounds of the orthodontists, the data collected from the self-assessment questionnaire showed the opposite viewpoint. This was probably because the questionnaire was subjective, whereas the time required for undertaking the procedures on typodonts was objective and accurately timed. It appears that wearing gloves routinely is the best way to reduce the inconvenience, and, as the outcomes of this study show, those who wore gloves during training and in current practice had fewer reservations than those who did not. Burke et al. (1992) considered that 42 per cent of orthodontists were capable of getting used to wearing gloves in practice in 2 weeks, with 33 per cent requiring only 2 months to adapt. With the intensive promotion of dental infection control in.

(8) 09_EJO27_1_cjh074_Cheng_D3. 10/2/05 8:58 AM. Page 71. P ROT E C T I V E G L OV E S I N O RT H O D O N T I C P R AC T I C E. 71. Taiwan during the past 10 years, increasing numbers of orthodontists are wearing gloves in practice. Even though some of them were reluctant to encompass these advances in cross-infection control, after limited training they did become used to it and did not experience as much inconvenience in actual practice as expected. Therefore, in order to develop high standards of crossinfection control, continuous re-education is needed. The influence of different geographical locations, cultural backgrounds, and perceptions of infection control need to be determined through a further study.. Centers for Disease Control 1987 Recommendations for prevention of HIV transmission in health-care settings. Morbidity and Mortality Weekly Report 36 (Supplement no. 2S). Address for correspondence. Crawford J J, Parker W D, Parker N H 1974 Asepsis in periodontal surgery. Journal of Dental Research 53: 99 (abstract). Hsin-Chung Cheng Department of Dentistry Taipei Medical University Hospital 252 Wu-Hsing Street Taipei 110 Taiwan ROC Email: g4808@tmu.edu.tw Acknowledgement The authors wish to thank the Research Foundation of Taipei Medical University for their support (TMU88Y05-A128). References American Dental Association Council on Dental Material and Devices, Council on Dental Therapeutics, Infection Control in Dental Offices 1978 Journal of the American Dental Association 97: 673–677 American Occupational Safety and Health Administration 1991 29 CFR part 1910, 1030. Occupational exposure to blood pathogens: final rule. Federal Register 56: 64004–64182 Brantley C F, Heymann H O, Shugars D A 1986 The effect of gloves on psychomotor skills acquisition among dental students. Journal of Dental Education 50: 611–614 Burke F T, Wilson N F 1989 The use of gloves in cross-infection control—a historical note. British Dental Journal 166: 426–428 Burke F T, Wilson N F 1991 Glove use in clinical practice: a survey of 2000 dentists in England and Wales. British Dental Journal 171: 128–132 Burke F T, Wilson N F, Shaw W C, Cheung S W 1992 Glove use by orthodontists: results of a survey in England and Wales. European Journal of Orthodontics 14: 246–251. Centers for Disease Control 1993 Recommended infection control, practice for dentistry. Morbidity and Mortality Weekly Report 42: 1–12 Cheng H C, Huang C S, Chen S C 1995 Compliance of Taipei dentists using barrier techniques in infection control. Chinese Dental Journal 14: 70–82 Cheng H C, Lin C T, Hong C L 1997 Infection control survey of Taipei dentists in the recent three years. Journal of Dental Research 76: 434 (abstract) Cooley R L, McCourt J W, Barnwell S 1989 Evaluation of gloves for orthodontic use. Journal of Clinical Orthodontics 23: 30–34. Davis D, BeGole E A 1998 Compliance with infection control procedures among Illinois orthodontists. American Journal of Orthodontics and Dentofacial Orthopedics 113: 647–654 Evans R E 1989 Acceptance of recommended cross-infection procedures by orthodontists in the United Kingdom. British Journal of Orthodontics 16: 189–194 Hardison J D, Scarlett M I, Lyon H E, Cooper T M, Mirchell R J 1988 Gloved and ungloved: performance time for two dental procedures. Journal of the American Dental Association 116: 691–694 McCarthy G M, Mamandras A H, MacDonald J K 1997 Infection control in the orthodontic office in Canada. American Journal of Orthodontics and Dentofacial Orthopedics 112: 275–281 Price D D, McGrath P N, Raffi A, Buckingham B 1983 Validation of visual analogue scales as ratio scales measures for chronic and experimental pain. Pain 13: 185–192 Rimland D, Parkin W E, Miller G B, Schrack W D 1977 Hepatitis B outbreak traced to an oral surgeon. New England Journal of Medicine 296: 953–958 Shaw F E, Barrett C L, Hamm R 1986 Lethal outbreak of hepatitis B in a dental practice. Journal of the American Medical Association 255: 3260–3264 Starnbach H, Biddle P 1980 A pragmatic approach to asepsis in the orthodontic office. Angle Orthodontist 50: 63–66 Uldricks J M, Caccamo P, Beck F M, Schmakel D 1985 Effect of surgical gloves on preclinical scaling skills. Journal of Dental Education 45: 316–317 Wilson M P 1986 Gloved vs. ungloved dental hygiene clinicians: a comparison of tactile discrimination. Dental Hygienist 60: 310–315 Woo J, Anderson R, Maguire B, Gerbert B 1992 Compliance with infection control procedures among California orthodontists. American Journal of Orthodontics and Dentofacial Orthopedics 102: 68–75.

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