Page 4 User Manual for CD3 INTRODUCTION Thank you for choosing an ARITECH security system. When properly maintained, the system will provide years of reliable operation. This manual explains how to use the ARITECH CD72 and CD95 series for every day use. Dexterous difficulties may considerably impede manual ADL function in PD, even at early stages of the disease. Impaired dexterity is typically less responsive to dopaminergic treatment. As a consequence, the development of standardized rehabilitation protocols for dexterity in PD is an important need.

• Aritech Cd 95 Manual Dexterity Test
• Aritech Cd 95 Manual Dexterity Review

History

Historically, the oral hygiene routine for frail elders who live in institutions was equivalent to placing a set of full dentures in a glass of water with an effervescent denture cleanser. Rarely, the mouth was rinsed and the oral mucosa or even the tongue was scrubbed. Nowadays, more and more natural teeth are retained until later in life, leading to an increased prevalence of fixed and partial dental prostheses among elders. Such dentitions require more sophisticated and time-consuming cleansing procedures that often exceed the competence of the caring staff and the time frame for oral hygiene in a patient’s individual nursing plan. The elders themselves may be uncooperative or show little motivation, especially when more severe general health issues overshadow the concerns for the mouth. Furthermore, they may lack dexterity and vision to perform oral hygiene measures adequately without assistance. Consequently, we often find a substantial bacterial load in elder persons’ mouths, which presents a considerable risk for infections and periodontal disease. Some 20 y ago, colleagues from Japan associated for the first time bacteria from the oropharyngeal tract with the incidence of aspiration pneumonia, thus introducing an additional aspect underlining the importance of oral health for the general well-being of elderly and fragile adults.

Pneumonia: The Leading Cause of Death from Infection in Elders

Pneumonia is a major threat to the older population, with an estimated incidence per 1,000 of between 25 and 44 in community-dwelling elders and from 33 to 114 in institutionalized elders (). Community-acquired pneumonia (CAP) and nursing-home-acquired pneumonia (NHAP) have to be distinguished. Pneumonia accounts for 13 to 48% of all infections in nursing homes and is the leading cause of death from infection in patients aged 65 y and older (). Reported mortality rates vary from 1 to 48% and are associated with age, comorbidities, and the severity of the disease (). Clinically, patients feel very unwell and present with cough, purulent sputum, fever, sweats, pain, and suffocation hazard. Very old persons often lack these classic symptoms and rather present with falls and confusion ().

Aspiration pneumonia is caused by foreign material descending into the bronchial tree and the lung alveoli, which, when originating from the oral cavity, may most commonly consist of food debris, saliva, biofilm, or a combination of these. Healthy adults may also aspirate some oropharyngeal secretions during sleep, but with coughing and ciliary transport as well as intact immune mechanisms, the airways are protected. With age and functional decline, these defense mechanisms become impaired, which renders fragile elders more vulnerable to developing aspiration pneumonia. Cognitive impairment, stroke, or other conditions that imply incompetent swallowing are the main risk factors for aspirating foreign material (). Ventilated patients are also at risk, even when not aged (). In a prospective study, 10% of 1499 community-dwelling patients who were hospitalized for pneumonia presented with aspiration pneumonia, whereas this percentage rose to 30% in 447 institutionalized pneumonia patients from the same study ().

The Role of Oral Pathogens

In samples of bronchoalveolar lavages from hospitalized pneumonia patients, microorganisms of denture plaque or associated with periodontal disease were found (). Quagliarello and coworkers described poor oral hygiene to be among the most common risk factors of pneumonia in nursing home residents (). From 9 modifiable risk factors, they identified only for inadequate oral care [hazard ratio (HR), 1.60; 95% confidence interval (CI), 1.06–2.35; P=0.024] and difficulty swallowing (HR, 1.65; 95% CI, 1.04–2.62; P=0.033), a significant association with the risk of developing aspiration pneumonia. In agreement with these findings, patients with 10 or more natural teeth and periodontal probing depths >4 mm showed a 3.9-fold greater risk of dying from pneumonia than those without periodontal pockets (). Oral pathogens may even persist after extraction of the natural teeth; hence, in edentulous subjects, tongue coating has been identified as a risk indicator for aspiration pneumonia ().

Effectiveness of Oral Care in Reducing the Risk of Pneumonia

Assuming that oral pathogens are at the origin of aspiration pneumonia, the question arises whether oral hygiene measures reduce the risk inherent to oral biofilm. Only a few randomized controlled trials have investigated the effect of oral hygiene measures on the incidence of pneumonia. One of the first studies was conducted by a Japanese group and reported on 417 residents from 11 nursing homes who were randomly allocated to an oral care or non–oral care group (, ). The intervention comprised 5 minutes of tooth brushing after every meal and professional hygiene provided once a week. When considered necessary, the regimen was complemented by povidone iodine swabbings. During the observation period of 2 y, new pneumonia had occurred in 34 of 182 elders of the non–oral care group, versus 21 of 184 residents who had received the intervention [relative risk (RR), 1.67; 95% CI, 1.01–2.75; P = 0.04]. Subsequent studies with various levels of evidence and different methodologies more or less confirmed these findings (; ). Whereas mechanical hygiene measures consistently seem to reduce the pneumonia incidence, the use of chemical agents alone yielded inconsistent improvement of the incidence of respiratory tract infections (). Van der Mareel-Wiernik et al. recommended tooth brushing after each meal, cleaning removable prostheses once a day, and professional oral health care once a week as the best regimen to reduce the incidence of aspiration pneumonia (). A systematic review concluded from 4 RCTs that 1 in 10 deaths from pneumonia in elderly nursing home residents may be prevented by improving oral hygiene ().

What’s New?

Toshimitsu Iinuma and his group from Tokyo evinced for the first time that denture wearing during sleep doubles the risk of pneumonia in very old persons (). The beauty of this finding is that this risk factor can be modified easily by a simple and straightforward clinical recommendation. It can be implemented by the patients themselves and requires neither manpower nor public funds. It enables patients to participate in infection control, even when impaired manual dexterity and vision preclude full autonomy in oral hygiene measures. The decision of whether to wear a dentures during the night has many facets. Generally, it is recommended to store removable dentures dry to prevent denture stomatitis, but psychosocial, functional, or mechanical aspects may influence the patient to still wear the dentures during sleep. Obviously, the risks of aspiration pneumonia and death, which seem to be associated with nocturnal denture wearing, add a new dimension to the pros and cons of wearing dentures while sleeping.

Conclusion

The available scientific evidence suggests that mechanical oral hygiene decreases the incidence of pneumonia in fragile elders. Hence, oral hygiene regimens for dependent elders should be rigorously implemented because they promise to reduce the morbidity and mortality from aspiration pneumonia. When possible, denture wearing during the night should be discouraged in geriatric patients.

Author Contributions

F. Müller, contributed to conception, design, data acquisition, analysis, and interpretation, drafted and critically revised the manuscript. The author gave final approval and agrees to be accountable for all aspects of the work.

Footnotes

The author received no financial support and declares no potential conflicts of interest with respect to the authorship and/or publication of this article.

References

• Abe S, Ishihara K, Adachi M, Okuda K.2008. Tongue-coating as risk indicator for aspiration pneumonia in edentate elderly. Arch Gerontol Geriatr. 47:267–275. [PubMed] [Google Scholar]
• Adachi M, Ishihara K, Abe S, Okuda K.2007. Professional oral health care by dental hygienists reduced respiratory infections in elderly persons requiring nursing care. Int J Dent Hyg. 5:69–74. [PubMed] [Google Scholar]
• Awano S, Ansai T, Takata Y, Soh I, Akifusa S, Hamasaki T, et al. 2008. Oral health and mortality risk from pneumonia in the elderly. J Dent Res. 87:334–339. [PubMed] [Google Scholar]
• Bassim CW, Gibson G, Ward T, Paphides BM, Denucci DJ.2008. Modification of the risk of mortality from pneumonia with oral hygiene care. J Am Geriatr Soc. 56:1601–1607. [PubMed] [Google Scholar]
• El-Solh AA.2011. Association between pneumonia and oral care in nursing home residents. Lung. 189:173–180. [PubMed] [Google Scholar]
• Iinuma T, Arai Y, Abe Y, Takayama M, Fukumoto M, Fukui Y, et al. 2014. Denture wearing during sleep doubles the risk of pneumonia in the very elderly. J Dent Res. doi:10.1177/0022034514552493 [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Imsand M, Janssens JP, Auckenthaler R, Mojon P, Budtz-Jorgensen E.2002. Bronchopneumonia and oral health in hospitalized older patients. A pilot study. Gerodontology. 19:66–72. [PubMed] [Google Scholar]
• Janssens JP, Krause KH.2004. Pneumonia in the very old. Lancet Infect Dis. 4:112–124. [PubMed] [Google Scholar]
• Quagliarello V, Ginter S, Han L, Van Ness P, Allore H, Tinetti M.2005. Modifiable risk factors for nursing home-acquired pneumonia. Clin Infect Dis. 40:1–6. [PubMed] [Google Scholar]
• Scannapieco FA, Bush RB, Paju S.2003. Associations between periodontal disease and risk for nosocomial bacterial pneumonia and chronic obstructive pulmonary disease. A systematic review. Ann Periodontol. 8:54–69. [PubMed] [Google Scholar]
• Shariatzadeh RM, Huang JQ, Marrie TJ.2006. Differences in the features of aspiration pneumonia according to site of acquisition: community or continuing care facility. J Am Geriatr Soc. 54:296–302. [PubMed] [Google Scholar]
• Sjogren P, Nilsson E, Forsell M, Johansson O, Hoogstraate J.2008. A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc. 56:2124–2130. [PubMed] [Google Scholar]
• van der Maarel-Wierink CD, Vanobbergen JN, Bronkhorst EM, Schols JM, de Baat C.2011. Meta-analysis of dysphagia and aspiration pneumonia in frail elders. J Dent Res. 90:1398–1404. [PubMed] [Google Scholar]
• van der Maarel-Wierink CD, Vanobbergen JN, Bronkhorst EM, Schols JM, de Baat C.2013. Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology. 30:3–9. [PubMed] [Google Scholar]
• Welte T, Torres A, Nathwani D.2012. Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax. 67:71–79. [PubMed] [Google Scholar]
• Yoneyama T, Yoshida M, Matsui T, Sasaki H.1999. Oral care and pneumonia. Oral Care Working Group. Lancet. 354:515. [PubMed] [Google Scholar]
• Yoneyama T, Yoshida M, Ohrui T, Mukaiyama H, Okamoto H, Hoshiba K, et al. 2002. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc. 50:430–433. [PubMed] [Google Scholar]

To many clinicians and public health scientists, using gloves, masks and eyeware when treating patients seems reasonable and rational. Although these devices are generally assumed and touted to protect both the patient and the dental staff, many dental scientists and clinicians seriously doubt the effectiveness of masks and gloves, citing the rarity of any disease transmission and numerous hazards associated with their use.^1-45 In this article, I will focus on examination gloves and document evidence-based facts that support the notion that glove use has been recommended on an unscientific basis and can increase the risk of infection rather than prevent it. Now that the AIDS scare of the 1990s has passed, and the disease is better understood, dependable scientific data is available to back this claim. It is time for a nonemotional re-evaluation of “protection.”

Government regulations, expanding the recommendations of the CDC, now require dentists to wear gloves with all patients. This may not be in the best interest of either the public or the dental professional. It has been proposed that the original recommendations of the CDC be re-applied. Those recommendations state that “gloves and protective ware be recommended, not mandated, for dental care and the use of these tools be determined by the clinician on a case-by-case basis where the benefits to the patient and safety of the dental staff be the prime focus.”

The Use of Gloves

Since 1985, concerns about AIDS and hepatitis B virus (HBV) have renewed emphasis on infection control and the use of barrier-protection devices in dental offices. From the original CDC recommendations, a variety of preventative extrapolations have been made by numerous self-proclaimed experts, organizations and manufacturers in an attempt to one-up each other while seeking wealth, attention and power. These recommendations have a great emotional appeal and range from the use of thicker glove materials and longer lengths to double- or triple-gloving. The ADA, CDC, OSHA and many state dental boards have recommended or mandated the use of gloves for all patient contacts.^1,2 Most dentists and their ancillary staffs wear gloves, most often composed of latex, which gives the best control and dexterity of all available glove materials.³ These elaborate exposure-prevention guidelines are based on a minimal amount of scientific data concerning the efficacy of barrier protection against viruses in a dental setting.^4,5 Almost all of the scientific data concerning safety and glove use in dentistry are extrapolations from the medical field. The use of gloves by health care personnel has been accompanied by a heightened incidence of glove-related problems.^36,38 Knowledge of these serious problems has been ignored or suppressed by many dental institutions in an effort to create a false sense of security among dental workers and patients who are led to believe that practicing Universal/Standard Precautions will protect them from all infections and dangers inherent in dental practice, and that not using Universal Precautions will doom them to certain death.

Barrier Protection and AIDS

Unlike glove materials, there are no known bacterial, viral or fungal life forms that are capable of penetrating intact skin.⁵ Intact skin is the best protection against infection. Nonsterile (contaminated) latex exam gloves are the choice of most dentists not only because of their lower cost but also because they interfere with dexterity considerably less than poorly fitting vinyl/nitrile gloves. Due to economics, few dentists use the more expensive sterile latex gloves for nonsurgical treatment. Before the 1990s AIDS panic, only about 20 percent of America’s dentists wore gloves, and this reflected concern mostly about HBV.^7,8

Unlike glove materials, there are no known bacterial, viral or fungal life forms that are capable of penetrating intact skin. Intact skin is the best protection against infection.

Before 1986, preventing HBV by wearing gloves was only occasionally mentioned in the literature.⁹ At that time, most dentists chose to operate bare-handed because they favored superior dexterity over questionable barrier protection.^7,8 Occupational infection of dentists or staff members was rare and even more rarely reported. In those relatively few HBV cases, the virus was transmitted by accidental needle sticks for which gloves would not offer protection.^1,9 The rarity of dental-related infections (HBV, herpes), low mortality rate and the recent development of HBV vaccines has made HBV a relatively preventable disease and therefore of less concern than in the past.¹⁰

AIDS, more than any other disease, prompted interest in barrier protection.^1-3 This poorly understood, fatal (now chronic) disease originally inspired fear and panic among the health care, government and public communities.¹¹ In the 1990s, fueled by media attention, civil rights of gay people, and governmental and scientific politics, AIDS took on the undeserved reputation as the nation’s “number one” disease. In reality, cardiovascular disease, cancer and diabetes killed millions more people each year.

The U.S. mortality rate for AIDS (2007) is 14,561 persons per year.¹² This is a statistically insignificant number (0.0005 percent) compared with the total population of the U.S. (305 million), yet it was once the highest funded and publicized disease.

Fear of contracting occupational-derived AIDS caused many professionals to quit their jobs or deny HIV/AIDS patients humane care. This irrational fear — fed by unsubstantiated anecdotal stories of infection from media, politicians, activists and “safety” merchants — required extreme action from the government and the surgeon general at the time, Dr. Charles Everett Koop. The CDC responded to the call with the concept of Universal Precautions. This was a form of cover-up ritual with enough emotional and quasi-scientific appeal to placate the professional and nonprofessional populace. Patients relaxed and those with HIV received treatment.

The technique of “protecting” oneself has been used throughout history. Although ineffective, it calms widespread panic. During the 14th century plague in Europe, physicians “covered up” in special cloaks to confuse the disease devils (Fig. 1). In the 1918 swine flu epidemic, useless cloth masks covered many faces in an attempt to protect from the flu, which killed 60 million people. (Some people were shot for failing to wear a mask.) In the 1950s, in preparation for a nuclear war, schoolchildren were taught to duck and cover under their desks (and not to run to the nearest bomb shelter). In the 1990s it was gloves, mask and eyeware to “cover” the skin and stop the spread of AIDS, which can only be transmitted from unprotected sex and IV drug use.

The first case of AIDS was reported in 1959, and since there have been no documented cases of occupational HIV infection in any dental health care worker.^1,13 There have been billions of dental patient visits worldwide with no disease transmission. There is one botched CDC investigation involving Dr. David Acer, an openly gay Florida dentist with HIV, who was alleged to have infected some patients (with secret high-risk behaviors). But even Dr. Acer wore gloves during all patient contact. In 1992, the U.S. General Accounting Office investigated and reported that this case was so bizarre, and the CDC did such a poor job in its investigation, that no reliable public policy should be drawn from the matter.^14,15 The GAO report did state that “gloves do not prevent most injuries caused by sharp objects, however, and so do not necessarily reduce contact rates.”¹⁴ The CDC also published six to seven “possible” HIV transmissions in dentistry, but these, in the words of CDC officials, “were short on science.”¹⁷

Primarily because of HIV-AIDS concerns, universal barrier protection, including the wearing of gloves, has been recommended and/or mandated for all dental staff when in direct contact with a patient.^1-3,7 This recommendation is still in effect. This has increased the use of gloves, along with problems associated with their use, for both staff and patient. Knowledge of these problems and hazards and the option of wearing gloves in appropriate situations are important for the health of the dentist, the dental staff and the patient.

Mechanical Hazards of Gloves

Aritech Cd 95 Manual Dexterity Test

Gloves pose a number of mechanical problems for the wearer:

Gloves do not offer protection against needle punctures, the leading cause of HBV and HIV infections in health care workers.^1,2,13,14,16 Eighteen of the 25 healthcare workers in North America and Europe who reported HIV occupational seroconversion during the years when AIDS first became a concern developed their infections from large-gauge needle puncture wounds.^1,13 This percentage has increased substantially over the years as the few new contamination cases reported needle stick-sharps injuries as the prime cause of seroconversion among medical staff. There have been no documented cases of dental staff occupationally seroconverting. Sharp punctures are not prevented by gloves.¹ In fact they have been shown to increase penetrating injuries.^17,18 The hazards of reduced touch sensation caused by gloves tends to contribute to clumsiness, which often results in increased skin penetrations due to the insulation of proprioceptive nerve endings in the skin of a dentist’s hands.^17,18 Solovan, et al. reported 2.3 times as many tissue lacerations in dental prophylaxis patients treated with gloves compared with work done bare-handed.⁸

1. In the largest clinical dexterity study to date, 50 dentists who practice in Lake County, Illinois, were tested for the average threshold for perception of light touch using a dynanometer.¹⁸ Results were 4.4 grams without gloves and 6.7 grams with their favorite gloves, which represents a 52 percent reduction in light-touch proprioception. There was a 16-fold increase in percutanious injuries while manipulating endo files (gloved) in a manual dexterity exercise as compared to the same dentists working bare-handed.¹⁸
2. Dental burs, especially those designed to cut acrylic, tend to snag the late rubber and drive the bur into the flesh of the operator’s hand, creating a deep penetrating wound¹⁹(Fig. 2). There is considerable danger in wearing gloves around rotating machinery.
3. Dental lathes and rotary devices can snag gloved fingers and have caused bone fractures among dental personnel.²⁰
4. Both latex and vinyl gloves are flammable and pose a danger with the use of open flame (e.g., wax in prosthodontics)²¹(Fig. 3).
5. Gloves increase the difficulty of handling small instruments such as pins, burs and endodontic files.^18,21 This impairment increases the time required to perform normal dental procedures and increases the opportunity for drop and aspiration accidents.²²
6. Gloves are also poor barriers to many solvents used in dentistry, such as alcohol, eugenol and methacrylates, as well as composite bonding agents and some impression silicones.^36,37 This allows contaminates to enter the gloves.

Problems with Barrier Protection

The primary purpose of the gloves is to provide a barrier to the transfer of microorganisms and other agents. They are fairly effective against organisms that are 10 microns or larger (e.g., bacteria), but there is little evidence that they effectively protect the wearer from viruses encountered in practice.^9,23 There have been numerous studies done that show minimal benefits for those who wear gloves.^9,15,24

New latex gloves have numerous porosities that are three to 15 microns in diameter.²⁴ These porosities increase in size and number when the gloves are stretched and used. Ten micron voids are the smallest imperfections that can be detected by usual testing methods.^24,26,27 The capsid of HIV is 0.1 to 0.12 microns in diameter.²⁷ A hundred of these viruses could pass side by side through one of the “natural” 10-micron openings in latex gloves. The HBV virus of hepatitis B is even smaller, 0.042 microns, which may partially explain why it is more infectious than HIV²⁹(Fig. 4). Vinyl and nitrile gloves have significantly more rips and openings.

Besides their natural porosity, latex gloves frequently have manufacturing defects in the form of visible holes 50 microns or larger in diameter.^27,30 From 2 percent to 36 percent of unused latex gloves and 23 percent of unused vinyl gloves examined had tears or holes that could allow fluids in a patient’s mouth to leak into the glove, causing “wet finger syndrome.”^26,27 These voids increase in size and number as the latex is worn or just exposed to atmospheric ozone^28,31(Fig. 5). This was corroborated in a report by Brough et al., which revealed holes in 37 percent to 70 percent of used postoperative surgical gloves.³²

In separate hallmark studies, both Reingold⁹ and Gonzalez³³ presented data showing that the use of gloves provides dentists little protection against HBV. Reingold studied 434 oral and maxillofacial surgeons and found that only the number of years in practice correlated with the number of infections these surgeons had incurred. The use of gloves showed no increase in protection. Gonzalez reported only a less than 3 percent decrease in HBV prevalence for dentists who wore gloves routinely compared with those who did not. His conclusion, that gloves are effective barriers, was criticized because it did not support his own data, which was statistically insignificant (p=less than .05). Reingold observed that many of Gonzalez’s HBV-positive reactors had more years in practice than glove-wearing nonreactors, which explained the greater number of HBV cases.⁹

Most reports on the effectiveness of gloves against viruses involve assumptions only. Hadler’s report,³⁴ which is unique because it was distributed by the CDC, is a typical example in which HBV was supposedly transmitted to patients by an oral and maxillofacial surgeon carrier. Prior to this discovery, the surgeon did not routinely wear gloves. No other HBV transmissions were noted after he began wearing gloves. The conclusion was that the gloves prevented further transmissions. Omitted from consideration was the later discovered shorter incubation period for HBV infection, the probability that the surgeon’s carrier status changed and that newly infected patients did not immediately test positive after the test surgeon began wearing gloves. This and three other similar studies were extrapolated by the CDC to apply to HIV infections and became the prime “scientific” rationale for the recommendation that gloves be worn as an element of Universal Precautions.¹ At that time, the AIDS epidemic was peaking and any rationale, scientific or not, would suffice for CDC action.

Eventually, the errors in this study forced the CDC to recant and recommend that vaccination be the only effective preventative measure for HBV. Retracting Universal Precautions would be embarrassing and spark the AIDS panic again and thus was not implemented. This constituted an official deception that had serious future consequences.

Gloves: An Expensive Contamination Hazard

Most dentists use nonsterile latex gloves instead of sterile gloves because of their lower cost.⁶ A 100-pair box of nonsterile exam gloves costs between $5 and $11 at most supply firms. Sterile gloves usually cost 10 times as much ($50–$95). The average dentist and staff uses $4,000 worth of nonsterile gloves per year (36 patients a day).¹¹ Extrapolating to the 150,000 dentists in America, the nation’s annual cost for dental gloves comes to at least $600 million. This is a tremendous expense for minimal to no benefit, because the wearing of gloves in dentistry has shown no significant improvement in reducing HBV (now addressed by vaccination) or AIDS (no documented cases of occupational transmission in dentistry before or after 1985). To invest this level of resources for a useless exercise defrauds the dentist, who pays the supply bill, and the patient, who pays the dentist.

Because the CDC and OSHA are primarily interested in protecting the dental staff member rather than the patient, the contamination potential (for patients) of nonsterile exam is placed secondary to the costs of glove supply. Both organizations, however, sensibly recommend sterile gloves for some surgical procedures. It is ironic that the nation’s health organizations insist on stringent infection control measures and advertise the fact as a safety promotion to the public, yet what they are advocating is that dental staff use contaminated (infected) exam gloves, rather than freshly washed and disinfected hands as was done before 1985.

Of course, using sterile gloves for all procedures would increase the cost of providing dentistry to such an extent (more than $5 billion annually) that no one would be able to afford dentistry. It is estimated that using sterile gloves as we do examination gloves would cost each dentist $40,000 more in supplies each year.¹¹ In spite of this, infections from bare-handed and gloved (sterile/nonsterile) dentists have been historically very rare and insignificant. Evidence-based science shows it doesn’t matter whether you wear gloves, and it never did. Yet dentists continue to believe that placing contaminated gloves on a compromised patient’s oral mucosa is safe and beneficial.

This is with the consideration that most latex glove products are manufactured and hand-packed in Third World countries, where facilities are hygiene-primitive and the bathroom hygiene of many latex workers consists of using the left hand as toilet paper. Soap and clean water is a rarity (Figs. 6, 7). Because exam gloves are considered already contaminated (nonsterile), they are seldom checked for pathogens. It is assumed that contaminated gloves are not clean. The hope is that they will be “kitchen clean,” which the CDC, dental organizations and dental boards assume is good enough for the population.

Microbe contamination is not the only problem. Gloves often are coated with talc or cornstarch, which act as lubricants and absorbents. There are problems with this, most notably that talc and starch are physical irritants.^36,37 They can cause inflammation in lesions on the wearer’s hands and can irritate wounds in the patient. Latex rubber ingredients have been identified as contributing to various degrees of dermatitis, as well as local and systemic allergic reactions.³⁹ Both talc and starch are irritants when inhaled and can cause asthmatic exacerbations in susceptible individuals.^28,36,40 The talc and starch will absorb latex proteins, become airborne and get inhaled by susceptible individuals. This can cause life-threatening conditions to breathing-compromised people (e.g., asthmatics). The incidence of latex sensitivity has increased from 3 percent to 6 percent in the general population since 1985 concurrent with widespread latex glove use. Some researchers consider this to be an epidemic in itself. The incidence of latex sensitivity in the dental community has soared from 3 percent to more than 22 percent.⁴⁷ This appears to be the direct result of wearing latex gloves and exposing skin and mucosa to the allergenic protein, as this problem did not arise until gloves became mandated. This is a dangerous change of events: Many deaths and thousands of serious reactions have been reported due to the increased latex exposure.⁴⁷ Another deception dentists and patients face is that gloves not only won’t be of much help in preventing disease, but they can cause considerable morbidity and mortality for which our patients and staff are seldom warned. This situation wastes money, endangers lives and discredits the dental profession.

This is with the consideration that most latex glove products are manufactured and hand-packed in Third World countries, where facilities are hygiene-primitive and the bathroom hygiene of many latex workers consists of using the left hand as toilet paper.

Starch is easily broken down into simple sugars that provide an ideal growth medium for microbes and contribute to bacterial and fungal growth on the warm hands of a glove wearer. This increase in resident and “leaked” microbial growth presents a danger to both the patient and the operator.^28,32 The components of latex (and other) gloves have been implicated as contamination hazards that may contribute to urticaria, nonhealing wounds, asthma, facial edema and toxic shock in health care workers.^30,38,41 Forty of the 50 dentists (80 percent) in a Lake County, Illinois, study wore gloves at least 85 percent of the time.²¹ Twenty-five (50 percent) of these dentists reported hand lesions concurrent with the wearing of gloves. Three of the remaining 10 dentists, who intermittently wore gloves, also reported hand lesions. All but one of these dentists attributed the lesions to the wearing of gloves.¹⁸ Tightly fitting gloves keep contamination close to the wearer’s skin surface. This increased contact encourages growth and spread of pathogens and increases the likelihood of allergies and/or reactions.

Nonsterile gloves are not only contaminated during manufacture but are also quickly contaminated by the natural flora of the hands. To illustrate, this author did an experiment. Thirty-one unused, multibrand, nonsterile gloves were swabbed with sterile saline/cotton swabs and individually plated on typto-soy media. Cultures were incubated for 24 hours. Six (19 percent) of these gloves were contaminated with gram-positive cocci, spore formers and fungi. There are numerous other studies that repeat these findings.^{16,23,24,26,29}

Considering that these microorganisms are augmented with a starch growth media, warmth and moisture from the wearer’s hands, the potential for increased contamination and skin breakdown of both the wearer and the patient is greatly increased. This is why the CDC recommends that dental health care workers who have exudative lesions or weeping dermatitis, particularly on the hands, should refrain from all direct patient care and from handling dental patient care equipment.¹ Because most dentists and their staff have microbreaks and other skin lesions as described above, obeying this order would essentially furlough 20 percent of the nation’s dental staff at any one time.

Allergy Hazards of Latex Gloves

Urticaria is a common complaint associated with the use of gloves.^36,39 In a Lake County, Illinois, study, half of the glove wearers experienced dermatitis.¹⁸ Increased IgE reactivity of wearers and patients has resulted in thousands of lifethreatening allergic reactions, such as anaphylaxis and asthma, to latex glove materials.^39-41 Additional allergic problems have resulted from the starch or talc used inside the gloves.³⁶ Contact with latex gloves by sensitized individuals has been life-threatening, as mentioned above.^39-41

Aritech Cd 95 Manual Dexterity Review

Between 1988 and 1992, the FDA received reports of more than 1,100 life-threatening systemic and 15 fatal reactions to latex. In recent years, as the population continues to be sensitized to latex (e.g., rubbing a gloved finger along the oral mucosa), this rate of anaphylaxis cases continues to increase. Both dentist and patient are at risk, and the deception that everything is safe cannot ethically be maintained.

Miscellaneous Hazards

Gloves also produce other problems not previously mentioned.

1. Latex has a negative taste and “sour rubber” odor to many people.⁴² Multi-flavored gimmick gloves are a poor attempt to correct this problem.
2. Hands are compressed by the elasticity of latex gloves. This restricts the flow of blood, which increases tension and muscle fatigue.⁴³ Although proper fit is important, the recommended snug fit is a disadvantage of glove use due to the elastic nature of latex and the wearer’s nerve pathology caused by the constant compression.³⁵
3. Gloves impede productivity by restricting movement, limiting manual dexterity and consuming time while gloving and degloving.^22,37,45 Assuming it takes 30 seconds to put on or take off gloves for each patient, a dentist who treats 100 patients a week for 50 weeks of the year loses 83 hours of productivity annually. This makes dentistry less efficient and more costly, and deprives the relative poor of needed care.
4. Many patients, especially small children, are offended by the use of gloves.³⁵ They interpret gloves as a threat or as an insult that they are dirty or diseased. This level of mistrust interferes with positive doctor/patient relationships.³⁵
5. The use of gloves has become an issue among the media, patients and dentists.^4,35 Many patients insist on being treated with or without gloves based on information gleaned from magazine articles, news reports and word of mouth. Most patients believe gloves are being worn for their protection, but OSHA recommends barrier protection for the expressed benefit of the dentist and other members of the dental staff, not the patient.² There will be serious consequences when the media learns that most dentists are treating their patients with contaminated exam gloves.
6. There are additional problems associated with wearing gloves. The use of adhesives, impression materials and electric pulp testers, which require direct skin contact, are all compromised.⁴⁵
7. Gloves are made of latex and plastic, which deplete natural resources, divert crop land (in the starving Third World) from food production and engorge our limited waste landfills with useless, unrecyclable garbage. If not buried, most gloves, being considered medical waste, are incinerated, producing hydrocarbon air pollution and CO2, and increasing the effects of global warming. Therefore, gloves are not green.

Politics

The most serious deceptions are in the political arena. The directives on Universal Precautions came from the CDC, a branch of the U.S. Department of Health and Human Services. This decision was made by a closed committee of public health bureaucrats, most of whom had never been in dental practice. It was an attempt to silence the AIDS panic, not to find the most efficient form of disease prevention.

Surgeon General Koop devised and promoted his UP concept for medical and dental personnel without any consideration of cost or effectiveness or outside input. On Oct. 29, 1999, The New York Times printed an expose reporting Koop was financially tied to a prominent glove firm, Allegiance Healthcare Corp. The article stated that he had received options to purchase 500,000 stock shares of the firm for a 1994 (low) price in exchange for four lectures per year and advertising rights to his name. This involved millions of dollars. Koop was accused of also trying to downplay the allergy danger issue in Congress because, as he told CDC representatives, “It would cause more harm than good and frighten hospital workers out of using gloves.” Eventually Koop ended up with a failed health care website, worthless stock, angry investors and a TV ad contract to sell “first alert” medical warning devices to the elderly. It seems that science was not a part of this formula.

It is amazing that dentists, their organizations, OSHA, dental boards and America as a whole accepted the pronouncements from the CDC, an organization of questionable authority and candor, without debate. The CDC has flubbed many health initiatives, the latest being the severity and criticalness of the H1N1 flu outbreak and botched vaccine supply.

In 1976 it also went out on a limb, declaring the swine flu of that year was the 1918 variety. It was not, though useless vaccines were distributed to the nation with hundreds of deaths and thousands of hospitalizations from adverse reactions. The anti-HIV cream Noroxnol-9, promoted by the CDC, was found to enhance the spread of AIDS, not hinder it. Former Surgeon General David Satcher called the CDC labs a national disgrace. Congress criticized the CDC for changing the definition of AIDS, thus doubling case numbers in an effort to garner more funding.¹⁷ This sad episode was termed by the CDC as “the distortion.”

Strange schemes appeared in the journals, such as ads stating, “Patients love headbags” or “$20 precision, plastic individual handpieces.”

A long series of crises, scandals, reorganizations, mistakes, policy flip-flops, infighting and political interference has left the CDC with a legacy of questionable competence. Because most infection control procedures are based on this flawed organization’s recommendations, dentists would be best served to be more critical than accepting of such government edicts.

The second area of political deception lies in dental publishing. Originally, a few articles on gloves and other PPEs appeared in 1980s journals rebutted by other papers opposing their routine use. As time went on, increasingly more journals printed unsubstantiated horror stories of dentists getting AIDS from patients and other rumors. They published increasingly bizarre recommendations from so-called infection control gurus increasing the panic. This brought attention and sold issues. Advertising for disposable (e.g., glove) manufacturers went from 3 percent to 25 percent of most dental publications’ ad space with the accompanying (financial) pressure on editors to avoid infection control criticisms, which would hurt business. Strange schemes appeared in the journals, such as ads stating, “Patients love headbags (a paper isolation bag with a hole for the mouth)” or “$20 precision, plastic individual handpieces (to ensure sterility and cracked enamel).” Some major dental organizations, profiting from the increased attention, adverted in their journals and took on the lead to perpetuate the deception that dentists were in danger of AIDS. They accepted whatever the CDC handed them, because protesting or questioning had some degree of political risk. Instead, they embellished the recommendations of extremes (e.g., heat sterilization of handpieces) to the detriment of the practitioners and their patients. Contemporary world regional geography 4th edition. Few journals protested and fearful dental staff embraced the deceptions with lemming enthusiasm.

Conclusion

Gloves are imperfect. They often contribute to the breakdown of the natural skin barriers. They are poor barriers to the transmission of viruses because of numerous voids derived from manufacturing and use. Gloves are cumbersome for the dentist to wear. Gloves are costly and allergenic, contain irritants, and breed microorganisms. The wearing of gloves is beneficial at times (e.g., deep surgery) but can be hazardous at others. The wearing of gloves should not be mandated by government edict but left to the discretion of the dentist in situations where the wearing of gloves provides more benefit than liability. As costs and glove-related illnesses increase, there is no rational scientific reason to continue routine glove use. It is time for dentists to decide what is best for their patients, not bureaucrats and hucksters. It is time for re-evaluation of glove use on a case-by-case basis.

What can be done? If the contaminated/sterile glove issue becomes public, there will be extreme pressure to replace exam gloves with expensive sterile gloves. Each practice will be required to spend at least 10 times more money on glove supplies. How much will this cost you? In this time of financial difficulty, in which many practices are in economic trouble and the excesses and window dressings of the wealthier past no longer can be comfortably funded, such costs would be ruinous. Many dentists will lose their jobs. Many practices will fold. The glove problem must be tackled sooner or later.

The problem with latex gloves is simple to solve. Dentists must pressure the CDC to declare that gloves are potentially hazardous and that its recommendations on mandatory UPs (including glove wear) are optional in those cases where UPs use is more detrimental than beneficial based on the dentist’s evaluation on a case-by-case basis. In this way, glove use will be determined by the doctor, not the bureaucrat. The blood-borne pathogen concerns of a medical heart surgeon need not be extrapolated to the dentist doing a prophy on a healthy 3-year-old. OSHA’s blood borne regulations already have this glove option, to a limited degree, in place (Federal Register 12-6-91. 56:235 p.64129d3ii). Once the CDC publicizes this change, dentists can once again take command of their practices. It’s your future and your patients’ health, and now is the time to act.