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Gowns, Gowns and more Gowns!!!

A summary discussion on product selection of gowns

The routine practice of PPE selection is based on a proper risk assessment. This involves choosing the appropriate uniforms, shoes, gloves, surgical masks, respirator masks, eye protection, face shields, gowns, hair caps and shoe covers. Depending on the practice setting, this entire line up may be your ‘norm’ or it may be a new PPE shopping experience if you were not using the complete PPE spectrum in the past. As the line up of PPE expands, decisions need to be made on specific products and their performance. This is simple when the products are regulated, and with any luck, that regulation includes registration with Health Canada (or FDA for USA) or at least inclusion in a medical class device listing.

gown

Gowns have several alias names: surgical gowns, isolation gowns, surgical isolation gowns, non-surgical gowns, procedural gowns, operating room gowns, single-use gowns, reusable gowns, etc. The Government of Canada defines the two gown types as the following:

  • Isolation gowns protect the clothing of health care providers. They also protect visitors and patients because they prevent the transfer of microorganisms and body fluids in patient isolation situations (1).
  • Surgical gowns are sterile textile gowns. Health care providers wear these gowns when they are working in a sterile environment (1).

“All medical gowns are classified as Class I medical devices. Class I devices present the lowest potential risk and are subject to the Medical Devices Regulations. Despite their classification as low risk, medical gowns serve an important function. Pathogens are unable to penetrate the material, which protects both the wearer and the patient.” (1)

How do you pick between an isolation gown and a surgical gown? Dental treatment is not offered in a sterile setting, therefore automatically eliminating sterile gowns. Now that being said, should an office wish to use sterile gowns, have at it as no one is putting the brakes on their use, however, be prepared to have a method for the sterilization of textiles. The office could potentially choose sterile gowns for the more invasive procedures, noted this is not a MUST in the standards.

Isolation gowns are the more typical choice for a dental office and they serve the purpose of a barrier to protect the health care professional (HCP) from splatter, spraying, droplets, droplet nuclei; the entire aerosol line up. The level of risk is highly tied to the type of services being offered. If the service is not generating aerosols (NAGP) a lower risk gown can be selected as there will not be any spray, splatter and aerosols. If the procedure involves aerosols (AGP) then a higher protection gown can be chosen as there is a potential for spray, splatter and aerosols. Nonsterile, disposable isolation gowns, which are used for routine patient care in healthcare settings, are appropriate for use (2).

What is the most important performance factor for a gown? Fluid resistance. Testing centres test gowns with various methods of fluid penetration: impact, hydrostatic, synthetic blood and viral. The following table form the CDC depicts the performance of gowns based on the ASTM and AATCC testing for potential fluid penetration. The more fluid resistance a gown demonstrates the more ideal its selection is for AGP. The following table from the CDC displays how each level is challenged, the result of the challenge and the expected barrier effectiveness. Note that the levels of 1-4 start with lower effectiveness to the fluid barrier and climb to a higher level of protection.

Figure 1. https://wwwn.cdc.gov/PPEInfo/Standards/Info/ANSI/AAMIPB70Class3

Table 3: ANSI/AAMI PB 70:12 classification of barrier performance of surgical gowns, other protective apparel, surgical drapes and drape accessories.

Level1 Test Liquid Challenge Result Expected Barrier Effectiveness
1 AATCC 42 Impact Penetration2 Water ≤ 4.5 g Minimal water resistance (some resistance to water spray)
2 AATCC 42 Impact Penetration Water ≤ 1.0 g Low water resistance (resistant to water spray and some resistance to water penetration under constant contact with increasing pressure)
AATCC 127 Hydrostatic Pressure3 Water ≤ 20 cm
3 AATCC 42 Impact Penetration Water ≤ 1.0 g Moderate water resistance (resistant to water spray and some resistance to water penetration under constant contact with increasing pressure)
AATCC 127 Hydrostatic Pressure Water ≤ 50 cm
4 ASTM F1670 Synthetic Blood Penetration Test (for surgical drapes) Surrogate Blood no penetration at 2 psi(13.8 kPa) Blood and viral penetration resistance (2 psi)
ASTM F1671 Viral Penetration Test (for surgical and isolation gowns) Bacteriophage Phi-X174 no penetration at 2 psi(13.8 kPa)
1 In order of increasing protection2 American Association of Textile Chemists and Colorists (AATCC) 42 Water resistance: impact penetration test determines the ability of a material to resist water penetration under spray impact [AATCC 2000]

3 AATCC 127 Water resistance: hydrostatic pressure test determines the ability of a material to resist water penetration under constant contact with increasing pressure [AATCC 1998]

Let’s compare the CDC table to the Government of Canada. The Government of Canada table has a simplified presentation and classifies the levels of the gowns as two main categories of Low and High risk into their intended usage and, like the CDC, uses the range of 1-4 for the levels. See Figure 2.

Figure 2.

Level of Gown Application for Use
Low Risk
1 minimal risk; used for standard precautions and simple procedures
2 low risk; used for minimally invasive surgery
High Risk
3 moderate risk; used for open gastrointestinal surgeries
4 high risk; used for open cardiovascular and trauma procedures

Adapted from: https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/covid19-personal-protective-equipment/gowns.html

Both tables are consistent in the levels of risk. From this information, it can be concluded that a dental office can safely utilize a level 1 or 2 gown and of course can still use a level 3 or 4 should they see the need. The deciding factor in dentistry, as stated earlier, is whether the services are AGP or NAGP. To help you navigate the maxill product line of gowns see Figure 3 for a table listing specific gown types, if they are reusable or disposable, their level # and the application into practice for either an AGP or NAGP (obvious that every gown can be used for NAGP but would be ‘overkill’ if choosing a higher level).

Figure 3.

maxill has a variety of gowns that are listed in the table below along with their performance.

Item # Disposable or Reusable Level Applicacion to Practice
53008 Disposable 1 NAGP
53460 Disposable TBD TBD
53480 Reusable 2 AGP
53010 Disposable 2 AGP

*Note: All gowns can be used for NAGP.

What about the gown selection for the reprocessing task? If an office's reprocessing routine includes manual cleaning with a brush and/or the use of an ultrasonic bath for instrument cleaning then automatically a gown is needed that can endure a potential splashing when moving the instruments in and out of the basket as well as rinsing them. A level 1 gown would not be the selection, but the level 2-4 would as this is an AGP (level 2 being very acceptable). Let’s compare that to an office that has no ultrasonic bath and uses an instrument washer and no manual scrubbing. What gown is then required? Here the selection is all levels and can include a level 1 gown as this is a NAGP.

Reusable gowns are growing in popularity and are a great environmentally-conscious option, yet they come with a few catches. The number of times they are washed must be tallied as they have an expiration on the number of uses. Each gown is traced and logged. For example, the maxill reusable gown has a limit of 75 washes and presents with a tally board inside the left corner of the panel that can be checked off with a fabric marker at each laundering. Utilizing the gown post its expiration date would conclude in the gown not living up to its intended performance. Laundering of reusable gowns can unfold on-site in a dental office or via a laundering service. It is not recommended to take gowns home for laundering. The following should be considered for a system of reusable gowns:

  1. Cost of the gowns
  2. Durability of the textile/fabric
  3. Staff expenses to collect, sort, launder, fold and store
  4. Energy costs for laundering on site
  5. Laundry room must be separate from operatories, reprocessing area and lunchroom
  6. Laundry room must have adequate air quality *dryer vented to the outside*
  7. Clean gowns must be stored, dispensed and retrieved in a method they are not contaminated
  8. Laundry machine and dryer must follow a proper cleaning and disinfection routine
  9. PPE is required to handle both the soiled and clean gowns
  10. The presence of distinct separation from the dirty ‘side’ to the ‘clean’ side in the laundry room
  11. The collection receptacles, if solid material, need to be disinfected and if fabric bags, the bags need to be laundered at every collection
  12. Decisions need to be made for the location of the laundry collection receptacles

Note: It is wise to consult with any dental regulatory body and / or public health for the directives of laundering of reusable gowns for your specific geographical area.

Dentistry was in the same boat years ago with the decision-making process of picking the mask for the task. A great catchy phrase that alerts us there will be a decision to be made for the mask selection ‘before’ donning the mask. We are being asked the same for gowns based on a proper risk assessment. Gowns are by far not new to the line up of dental PPE and have been part of the educational IPAC curriculum in dental schools for several years. Any dental grad from the last 10 years will remember strict protocols of when and when not to don a gown as well as proper doffing steps. Knowing more information about gowns hopefully solves some dilemmas for selection and usage. The dental PPE line up is full. With all these PPE layer’s be sure to lower the thermostat setting. Remember to ‘pick the mask for the task’ and ‘go to town with the right gown’!


Resources

1. Government of Canada. Personal protective equipment against COVID-19. Medical gowns. 2020. https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/covid19-personal-protective-equipment/gowns.html?wbdisable=true 2. Centre for Disease Control. Personal Protective Equipment: Questions and Answers. March 14, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq.html 3. Centre for Disease Control. Strategies for Optimizing the Supply of Isolation Gowns. 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html


Michelle Aubé (Simmonds), RDH, maxill Dental Hygiene Educator

Michelle is a Dental Hygiene Speaker, Consultant and Educator with over 21 years of experience as a RDH and 4 years as a CDA. She has written dental hygiene articles for CDHA’s OH Canada professional publication and continues to practice clinically and teaches both clinical dental hygiene and practice management at Fanshawe College and the University of Western Ontario. She has served on the Discipline Committee at Algonquin College and held the position of a CDHO Quality Assurance Assessor for 7 years.