Category: Compliance

The Centers for Disease Control and Prevention (CDC) set the water quality standard for dental unit treatment water at ≤500CFU/ml of heterotrophic bacteria. Many dental practices are treating their dental unit water by placing a tablet or liquid in the water bottle or utilizing a valved cartridge (referred to as straws) in the water bottle to control the growth of biofilm and improve water quality. However, many practices assume that the product they use is working and that they are meeting the CDC’s water quality standard. The bottom line is that if you don’t test your dental unit water, you don’t know if you are meeting the standard. These are 9 things that you need to know about dental unit water quality. 1 - Patients can and have developed bacterial infections from contaminated dental unit water. In 2015, 24 pediatric patients at a facility in Georgia developed Mycobacterium abcessus infections from exposure to contaminated water during pulpotomy procedures. In 2016, a similar outbreak occurred in California, involving 71 patients, who were hospitalized to treat the infections. More recently, the CDC issued a Health Alert through its Health Alert Network (HAN) emphasizing the importance of following recommendations for maintaining and monitoring dental unit water quality, based on past incidents and an ongoing investigation of yet another outbreak of infections. None of these outbreaks have resulted in patient deaths, however, 2 patients have died from Legionella infections contracted in dental practices from dental unit waterlines. 2 – Using distilled or filtered water in dental units does not prevent biofilm formation and water contamination. Some dental professionals equate distilled water with sterile water – meaning that it has no microorganisms, that can contribute to the formation of biofilm in the dental unit waterlines. This is not true, however. Whatever type of water is used in the dental unit, something must be done or added to the water to maintain the safe water standard. There are a number of options that dental practices can implement to maintain safe water, including the addition of an antimicrobial tablet or solution each time the water bottle is filled, installing a valved cartridge or straw) into the water bottle, installing a whole-office or point-of-entry water purification system, in addition to utilizing municipal water connected to the dental unit or in a separate water reservoir/bottle. It is very important to consult the manufacturer’s instructions for the use of the equipment to determine the recommended method of treating the water in the dental unit. Waterline disinfectants/maintenance products act to inhibit the growth of bacteria and biofilm formation but do not prevent it. 3 - Surgical procedures require the use of sterile water or sterile saline for irrigation. Due to the risk of introducing microorganisms into a sterile body cavity during surgical procedures, water from the dental unit should not be used to irrigate surgical sites. Sterile water or sterile saline can be dispensed from a sterilized bulb syringe or through the use of a specifically designed sterile water delivery system, that can be sterilized after each use. Placing sterile water or sterile saline into the dental unit water bottle does not ensure that the water is sterile when it exits the dental unit since it is exposed to the biofilm present in the dental unit waterlines. 4 – Most waterline maintenance products require a periodic shock treatment of the waterlines. The manufacturers of dental unit waterline disinfectants/maintenance products have recommendations for a shock or cleaning treatment for the waterlines. The manufacturer of the disinfectant determines how often the shock treatment should be performed which may vary depending on the product used. Shocking involves adding an antimicrobial solution, usually at a higher concentration than the maintenance product, and leaving it in the lines overnight. This procedure will clean the lines and remove biofilm. Some products require three consecutive treatments to clean and remove all of the biofilm that has accumulated. Always follow the manufacturer’s instructions for the use of both waterline disinfectants and shock products – as they are not interchangeable. 5 – If you don’t test your dental unit water, you don’t know if you meet the safe water standard. Although the products used in dentistry to treat and shock the dental unit waterlines have been tested for efficacy, there are many variables that can affect whether the product is working effectively in each dental unit. The only way to assess that the water meets the ≤500CFU/ml standard is to test the water in each unit. Testing the water can be done in-office or mailed to a water laboratory. The CDC states that testing should be performed “periodically”, however, most manufacturers recommend quarterly testing. If the dental units in your facility have never been tested, a best practice would be to test all the units as a baseline. This can help identify any issues with specific units or individual waterlines. If any of the dental units do not meet the water quality standard, the lines in those units should be shocked and then retested. Be sure to record all test results for each dental unit. 6 – There are two ways to perform dental unit waterline tests. The first method is to do a pooled test. This involves dispensing equal amounts of water from all the lines on a dental unit (air/water syringe, handpieces, and scalers) into the test container. The other is to test each waterline individually. Most practices use pooled samples. Testing individual lines is typically performed when the unit continually fails, and further determination is needed to find the source of the contamination. Always follow the manufacturer’s instructions for conducting the test. 7– Dental unit waterline tests are not meant to identify specific microorganisms in the water. Dental unit waterline test kits are designed to determine the number of colony-forming units of bacteria in the water sample. In other words, does the water meet the standard or not. There are some water labs that will analyze the microbial content of the water, but it is usually not necessary for dental facilities unless a specific problem has been identified. 8 – Contaminated dental unit water is also a risk to the dental team. While we tend to think of the risk to patients from exposure to contaminated dental unit water, the clinical team members are exposed to aerosols from that water (and saliva/blood from the patient) during most of the procedures that they perform each day. When dental handpieces, air-water syringes, and ultrasonic scalers are utilized, the aerosols created contain microorganisms that are contained in the biofilm in the lines. If the clinical team is not wearing appropriate personal protective equipment (PPE), they can also be exposed to potential transmission of infectious diseases from the dental unit waterlines. 9 – Dental practices should have written protocols for maintaining and testing their dental unit waterlines. Consistency and accuracy are the keys to achieving safe dental treatment water for patients and team members. Written protocols, or standard operating procedures, help to ensure that each team member knows how to perform waterline maintenance procedures. Keep in mind that not all the dental units in a facility are the same, and different equipment may require slightly different protocols. As previously mentioned, the practice should also maintain documentation of waterline testing and shocking, in order to prove that the procedures have been done and make sure that no units have gone untested or untreated. Dental unit water quality has been in the news a great deal over the past several years. Be proactive about your dental unit water quality by testing and following the recommended procedures for your equipment and the products that you use. Let your patients know that you do your utmost to provide them with safe care – including safe water. CDC Morbidity and Mortality Weekly Report (MMWR), April 8, 2016, Notes from the Field:  Mycobacterium abcessus Infections Among Patients of a Pediatric Dentistry Practice – Georgia 2015. https://www.cdc.gov/mmwr/volumes/65/wr/mm6513a5.htm   CDC Health Alert Network (HAN) Outbreaks of Nontuberculous Mycobacteria Infections Highlight Importance of Maintaining and Monitoring Dental Waterlines https://emergency.cdc.gov/han/2022/han00478.asp   CDC Healthcare Water Management Program Frequently Asked Questions https://www.cdc.gov/legionella/wmp/healthcare-facilities/healthcare-wmp-faq.html

HIPAA compliance has become normalized in dental practices across the country. In some instances, it is almost taken for granted after 20 years since the first Privacy Rules were implemented. Dental practices are, however, being audited by HIPAA’s parent agency – the Dept. of Health and Human Services (DHHS), and complaints are filed by patients and investigated by HIPAA’s enforcement agency – the Office for Civil Rights (OCR). Since dental practices can be cited and fined for non-compliance and/or violations resulting from audits or complaints, it makes sense to examine the most common violations and strategies to avoid them. 1. Lack of Employee Training All employees, both administrative and clinical, must receive initial training (i.e., when they are hired) as well as annual training updates. Training topics must cover the provisions of the Privacy Rules, Security Rules, and Breach Notification Rules. Training can be provided by a knowledgeable member of the team, an outside consultant/trainer, or through video and online training programs. If a prerecorded video program is used, the employer or practice administrator must plan for answering employee questions regarding the training information presented. A dental practice must keep records of all HIPAA training and will need to produce those records in the event of an audit or complaint. 2. Failure to Document Privacy and Security Policies A key component of HIPAA compliance is a written set of policies and procedures for providing for the privacy and security of patients’ protected health information (PHI). A dental practice can access templates for these policies from the DHHS at https://bit.ly/3ZbpuNY , by working with a HIPAA consultant, or by purchasing a HIPAA compliance manual from various sources, such as the American Dental Association at https://bit.ly/45KmtqE. 3. Lack of Business Associate Agreements Business Associate Agreements are essentially contracts between a covered entity (dental practice) and a business or support service who need to access patient PHI to provide their services. This also includes any contractors that a business associate utilizes to provide services to the dental practice. The purpose of this agreement is to ensure that the business associate provides all necessary safeguards to protect the privacy and security of the dental practice’s PHI. Some examples of business associates are consultants, technology support companies, software vendors, and healthcare claims clearing houses. Information on Business Associate Agreements is available from DHHS at https://bit.ly/489Wri0 or from a HIPAA consultant or a purchases HIPAA compliance manual. 4. The Practice’s Notice of Privacy Practices is not posted The HIPAA privacy rules require that a covered entity/dental practice develop a Notice of Privacy Practices (NPP), which details the ways in which the practice protects the privacy of PHI and how it may be used for Treatment, Payment, and Operation of the practice. This document must be posted in a prominent place where patients have access to it, including on the practice’s website, and a copy must be provided to a patient or parent on request. Since this document is several pages long, it may take up a fair amount of space if it is framed and hung on the wall. An option would be to format the document into a foldable brochure (printed in landscape format) and place it in a brochure holder in the reception area. Copies can also be laminated and available in the check-in area of the front desk. The NPP must indicate the name of the privacy officer/manager, how to contact them, and how to file a complaint. If the person designated as the privacy officer changes, the NPP must be updated. A template for a NPP is available from the Dept. of HHs at: https://bit.ly/44MAm6c. Currently, the HIPAA rules require that patients/guardians sign an acknowledgment that they have been given access to the NPP, which is commonly referred to in practices as the “HIPAA form”. Proposed changes to the HIPAA rules indicate that this may not be necessary when these changes become effective (possibly in 2024). It is important to note, however, that practices should continue to obtain this acknowledgment for now, along with the names of individuals with whom the practice may communicate about the patient’s treatment. This would include spouses, parents of dependent children who are over 18 years of age, and adult children of elderly patients. Parents and guardians of minors always have the right to discuss treatment. 5. Failure to conduct an annual Security Risk Assessment (SRA) This provision of the HIPAA Security Rules is critical to the safety of electronic data in a practice. The purpose of this document is to assess whether there are risks to the security of PHI in the practice, rate the severity of the risk, and develop a strategy and timeline for mitigating those risks. Some of the information that is addressed on an assessment form may be beyond the expertise of the security officer or practice owner. Working with a technology support provider is a good practice for completing this assessment. The Dept. of HHS has an online SRA available at: https://bit.ly/3Pwg9NJ . 6. Failure to correct issues identified in the Security Risk Assessment A key mistake that many dental practices make is to complete the assessment form each year, but not address any of the risks that have been identified. In cases of HIPAA audits or investigations of complaints, the HIPAA auditors/investigators ask to see and thoroughly review the SRAs for a covered entity/practice. If any items identified as risks have been continually identified, but not addressed, citations and fines will be assessed. 7. Allowing access to patient-protected health information to unauthorized individuals This issue has many facets. It may include access to paper records or electronic records. In the case of paper records/charts and other documents with PHI, those documents must be kept secure, especially if there are cleaning professionals (who are not employees) who are present in the office after hours. The patient charts should be stored in lockable file cabinets or in a locked room, that only employees have access to. These service providers are not covered by BAAs, since their job doesn’t require them to access patient information. Cleaning staff and other service providers who may be at the office after hours when no employees are present should have a signed confidentiality agreement, in the case of patient information that may not be secure. Securing electronic PHI begins with using secure passwords for logging in to the practice management software. Each team member that has access to the software must have their own password. Technology experts say that passwords should be as long as the software allows (up to 20 characters), including upper and lower case letters, numbers, and special symbols, such as #, $,!. Passwords need to be changed regularly and most practice management software programs now have a default of 60 – 90 days for changing passwords. Team members should never use another team member’s password for logging in, nor should they disclose their password to anyone outside of the practice. A common practice is to write the password for a workstation on a sticky note and place it somewhere on the keyboard or monitor. This practice is not allowed. When team members leave their workstations for longer than a few minutes, or for lunch, they should either log out or lock the screen to prevent unauthorized access. Locking the screen is achieved by a number of keystrokes, and then repeating those keystrokes to unlock it upon returning to the workstation. Some software will allow the creation of a “hot key” that will execute this command. Check with your software provider to determine how to do this. Another way to lock the screen is to press the ctrl, alt, and del keys at the same time. This will either cause the screen to go blank or bring up the task manager. If the task manager comes up, select the lock, and the screen will go blank. Performing this same task on returning will again bring up the task manager and require logging back into the software. The user will be taken back to the patient record or task that they were working on when they locked the screen. 8. Sending electronic patient-protected health information by unsecured and/or unencrypted email There has been a great deal of resistance on the part of dental practices to adopt safe transmission practices with patient information. As many practices are utilizing digital radiography, emailing copies of these images is easy and convenient, when making referrals, or for transferring patients. But emailing this PHI through unsecure email channels is risky since the email can be intercepted during transmission. In most cases, the information that dental practices send is not highly sensitive, but if the message and attachment are not encrypted, it can allow hackers access to the practices’ server where the images are stored. Email hacking is also a security risk in that it can be infected with viruses and other malware. Dental practices should first use secure email. Secure email is achieved by utilizing the email services connected to the practice website, or by redirecting an existing Gmail or other account to a secure portal. Technology and web support services can assist with this. The benefit of using a secure email portal is that it greatly reduces the possibility of being hacked. Gmail, Yahoo, and other free email providers do not have the level of security needed for HIPAA compliance. Even if the practice is using secure email, any attachments with patient information must be encrypted, or transmitted through a virtual private network (VPN). Encryption typically requires a subscription to an app that copies the attachments, secures them in a vault, and makes them available to a recipient who logs in to the encryption service vault. Some of the encryption services can be integrated into the practice management software, requiring fewer steps to send the email and attachments. HIPAA rules exist for the protection of patient information and to protect a dental practice from liability if that information is accessed inappropriately. Protecting the privacy and security of patient’s information is not only a legal issue but an ethical issue as well. If a practice strives to provide the highest level of care, that includes protecting the patients’ information. Privacy and security issues are also good business practices, which all dental practices need to follow.

The answer to this question is yes – but not to the level of concern during the pandemic.   The CDC, World Health Organization (WHO), and the news media are reporting increases in hospitalizations of patients with COVID-19, and two fast-spreading variants of the Omicron COVID variant. In addition, we are now entering into the very early stages of flu season, and the spread of Respiratory Syncytial Virus (RSV).   It is important to remember that dental practice facilities are at a higher level of risk for transmission of respiratory viruses because of the aerosols that are produced while providing treatment.    There is some discussion online and on news channels about the possibility of reinstating mask mandates.  Some hospitals have already instituted the mandates if the number of cases and hospitalizations are high in their area.  There is no mandate for dental practices to require patients to wear masks when they enter the facility, and this likely will not happen unless the cases increase very significantly. So, what do dental teams need to do at this time? First, dental teams should continue to screen patients prior to their appointments for the presence of respiratory symptoms.   If a patient is experiencing symptoms, the CDC recommends postponing treatment, unless there is an emergency.  Unless the patient has been tested (not likely), there is no way to know whether they have COVID, influenza, or RSV. There are tests available that screen for all three viruses, but they are not widely sought out by patients through healthcare providers. Current guidance from the CDC is accessible here:  https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html.  Keep in mind that while these are “recommendations”, many state dental boards require following CDC guidelines. These recommendations include using an N95 respirator or a higher level of protection for patients with confirmed or suspected COVID-19 (for emergency treatment). Second, teams should consider the types of masks or respirators that are used during treatment. Many dental team members have already ditched the respirators and gone back to using face masks for all patients. Masks with ASTM Level 3 ratings are the appropriate choice for aerosol generating procedures (AGPs).  But the limitation of these face masks is that they do not seal on the face like a respirator.   Many masks gap on the top and sides.   Teams should purchase masks that fit well and minimize the gaps.  Just to review – AGPs include the use of high-speed handpieces, air/water syringes, ultrasonic scalers, air polishers, and air abrasion.   In addition, the KN95 masks that were allowed under the Emergency Use Authorization (EUA) from the FDA during the pandemic are no longer allowed for use in health care settings, as they do not meet U.S. criteria for face masks or respirators and are not cleared by the FDA. Third, team members should stay home if they have respiratory symptoms.  Just as our patients may be infectious to us, we can be infectious to the patients and to co-workers.  A practice should have a clear policy defining what protocols should be followed if a team member has a respiratory infection as well as what to do about patients who indicate prior to their appointment that they have symptoms, or who present at the office with symptoms. And last but not least, consider getting a COVID-19 vaccine or booster if you have already been vaccinated.   The most updated vaccines are anticipated to be available by the end of September.   Check with your health care provider, local health department or pharmacy for information about vaccines and boosters.   It also is a good idea to get an influenza vaccine, which are currently available. Most of us are COVID-weary and don’t want to think about all of the craziness that happened during that time.   But COVID-19 is still a health threat, as are other respiratory infections.   As dental health care professionals, we need to protect our health as well as the health of our patients.   As with any vaccine recommendations, always check with your health care provider to make sure that they are appropriate for you and your current health status.    CDC Updates Respiratory Virus Updates https://www.cdc.gov/respiratory-viruses/whats-new/index.html

Now that COVID-19 isn’t dominating the infection control news stories (although it is still present), we turn our attention to some additional news regarding infectious disease transmissions that may affect us in dentistry.  Some of the information is good news and of course, some is not so good.   Recently the Food and Drug Administration (FDA) granted approval for two new vaccines for Respiratory Syncytial Virus (RSV).,  The vaccines are the first for preventing this serious respiratory virus.  According to Gavi The Vaccine Alliance, RSV infects millions of people globally each year with lower respiratory tract infections, with mild symptoms.  Young children and older adults are particularly vulnerable, and many are hospitalized for treatment of the infections.  RSV infections can also be fatal, especially in patients with underlying medical conditions. These new vaccines, approved for individuals over 60, is reported to reduce the risk of severe RSV-related lower respiratory disease by 94%.  RSV is characterized by the Centers for Disease Control and Prevention (CDC) as an infection of the lower respiratory tract that includes symptoms of runny nose, decreased appetite, coughing, sneezing, wheezing and fever.   These symptoms are similar to COVID-19 and influenza however, a single nasal swab test (PCR) can detect which of these viruses is occurring in a patient.   Some danger signs in children and adults that indicate the need for immediate medical intervention include difficulty breathing, stridor (wheezing, grunting or high-pitched sounds with each breath), coughing or wheezing that does not stop, decreased alertness, bluish skin, tongue or lips, dehydration, and high fever (104°F).  According to the CDC, in the 2022-2023, the overall rate of RSV-associated hospitalizations was 51.9% per 100,000 people.  The CDC’s National Respiratory and Enteric Virus Surveillance System (NREVSS) is an excellent resource for dental health care providers to monitor RSV, influenza and other respiratory virus trends in the area where their dental practices or clinics are located.   This information is updated weekly by states and regions in the U.S. If the pandemic taught us anything in dentistry, it is that the threat of respiratory infections can be serious, and that dental health care personnel are at risk of exposure from patients and from each other.   Even though the pandemic is over, endemic COVID-19, influenza and RSV infections continue to spread.  Reappointing patients who have respiratory symptoms should be a standard protocol in every dental practice, with the exception of patients needing emergency treatment. The CDC recently reported that cases of malaria were identified in Sarasota County, FL and Cameron County, TX.  These four cases, not related, are believed to be locally acquired, which is not as common as cases that are acquired when individuals travel to countries where malaria is common.   Malaria is a parasitic infection, transmitted through mosquito bites.  If not treated, malaria can be fatal.  The CDC, along with state and local health departments are increasing efforts to raise awareness among professionals and the public of the potential risk of malaria and other mosquito-borne infections.   Preventive measures include DEET-containing insect repellent, loose-fitting long-sleeved shirts and pants and utilizing screens on doors and windows.  Symptoms of malaria infection include: fever, shaking chills, headache, muscle aches and fatigue.  Nausea, vomiting and diarrhea can also occur, along with anemia and jaundice.  If not treated promptly, malaria infection can cause kidney failure, seizures, mental confusion, coma, and death.    Candida Auris According to the CDC and the Association for Professionals in Infection Control and Epidemiology (APIC), Candida Auris (C. auris) is an emerging fungus, discovered in Japan in 2009.  It is considered to be an urgent antimicrobial resistance threat.   The CDC states that it is spreading at an alarming rate in hospitals and long-term care facilities.  Of great concern to health care professionals is that C. auris is difficult to identify, often is mistaken as a bacterial infection, and medical laboratories must have specific technology to correctly identify it, which is beyond standard laboratory methods.  The most concerning issue is that C. Auris is resistant to the most commonly used antifungal medications.   It is easily spread in health care facilities and is especially harmful to individuals who have weakened immune systems.  In these individuals the infection may enter the bloodstream, causing what is described as an invasive infection. Although no cases of C. auris infections have been associated with oral health care, it is possible that an infectious patient may be treated in a dental practice.  Patients may be ill from other types of medical conditions, and they may be experiencing fever and chills as the result of a C. auris infection.   This reinforces the need to monitor every patient’s vital signs, including temperatures, at the beginning of each visit.   During the pandemic, the CDC recommended checking temperatures before patients were admitted to the dental office.   While that is no longer necessary, taking a patient’s temperature and blood pressure is considered a good medical practice.  And the temperature and blood pressure needs to be recorded in the clinical note.   Unless it is an emergency, or the fever is believed to be caused by a dental infection, these patients should be reappointed until they are well enough for oral health care procedures. In addition, if appropriate disinfecting protocols are not followed with all patients, C. auris could be spread to other patients and dental health care professionals.   In most cases the tuberculocidal disinfectants that are used in dentistry will be effective against C. auris, but dental professionals can look up their disinfectants on the Environmental Protection Agency (EPA) list for emerging pathogens to determine if the product they use is effective against C. auris. Dental Unit Water Quality Bacterial infections resulting from patient treatment using untreated, contaminated dental unit water continue to be investigated by the CDC.   While most of the cases identified have affected pediatric patients who received pulpotomies, adult patients have been infected as well.   The CDC states that any dental unit with untreated water is a potential infectious disease threat to patients.   It is also a threat to dental health care providers as well, due to the exposure to aerosols created from that water. Much attention has been directed at how to treat the water, and there are many products on the market that are effective in controlling microbial contamination, but the issue still exists.   There are several reasons why this is the case, including a lack of consistency in using the waterline cleaner/disinfectants, not following the manufacturer’s instructions for use of the product, lack of shock/cleaning of the dental unit waterlines according to the equipment manufacturer's instructions and product instructions, and a lack of testing to determine if the products or procedures followed are actually working. Every dental practice needs to have a waterline protocol in place that includes training for the team to understand the risks of using contaminated water, selecting the appropriate product that is compatible with the dental units in the practice, a testing protocol, and a protocol to follow if a dental unit fails to meet the CDC recommended <500CFU/ml.   The CDC has a great deal of information on its website about dental unit water quality that can help guide a dental practice to establish and follow the necessary protocols. Taking a Broader View of Infection Prevention and Control As dental professionals, we sometimes view issues in a narrow context – only looking at what directly affects the delivery of oral health care.   It is important to recognize, however, that comprehensive oral health care includes recognizing what is occurring in the global context of infectious disease.  In many cases dental professionals dismiss some issues as irrelevant because very few or no infections have been documented in dentistry or are unlikely to occur in dentistry.   Dentistry is a profession of preventing oral disease and should also be a profession of preventing the spread of infectious diseases. U.S. Food and Drug Administration: https://www.fda.gov/vaccines-blood-biologics/abrysvo U.S. Food and Drug Administration: https://www.fda.gov/vaccines-blood-biologics/arexvy  Gavi.org  https://www.gavi.org/vaccineswork/rsv-vaccines-are-we-close-taming-one-worlds-biggest-killers-children  DC RSV-NET: https://www.cdc.gov/rsv/research/rsv-net/dashboard.html#:~:text=In%20the%202022%2D2023%20season,was%2051.0%20per%20100%2C000%20people. CDC NREVSS: https://www.cdc.gov/surveillance/nrevss/rsv/state.html  CDC: https://www.cdc.gov/malaria/new_info/2023/malaria_florida.html CDC FAQ’s About Malaria: https://www.cdc.gov/malaria/about/faqs.html  CDC Increasing Threat of Spread of Antimicrobial-resistant Fungus in Healthcare Facilities: https://www.cdc.gov/media/releases/2023/p0320-cauris.html  CDC Invasive Candidiasis: https://www.cdc.gov/fungal/diseases/candidiasis/invasive/index.html  EPA List P: Antimicrobial Products Registered with EPA for Claims Against Candida Auris: https://www.epa.gov/pesticide-registration/list-p-antimicrobial-products-registered-epa-claims-against-candida-auris   CDC Dental Unit Water Quality: https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention-practices/dental-unit-water-quality.html

During the COVID-19 pandemic, both OSHA and the Centers for Disease Control (CDC) recommended that dental treatment rooms have increased ventilation and air purification to remove potentially infectious aerosols.   In its updated guidance for COVID-19 from (May 8) and for Ventilation in Buildings (May 11, 2003); the CDC makes specific recommendations about the use of HEPA air filtration systems, the recommended number of air exchanges in the office, and recommendations for operating the heating, ventilation, and air conditioning (HVAC) systems. Why is the CDC still recommending these enhancements?   Because COVID-19 is still spreading, although not at a pandemic level currently.   There are also numerous other airborne infectious diseases that can be transmitted in a dental setting, including influenza, respiratory syncytial virus (RSV), measles, chicken pox, tuberculosis, and others.   Those risks were present pre-COVID-19, but the pandemic brought this concern to the forefront, especially with respect to aerosol generating procedures (AGPs).   AGPs include the use of an air/water syringe, high-speed handpiece, ultrasonic scaler, air polishing, and air abrasion.,   These recommendations are made in addition to that of increased use of high-volume evacuation (HVE), to assist in containing aerosols during treatment.   In addition to infectious disease transmission risks, dental team members are also potentially exposed to chemical hazards, such as disinfectants, methyl methacrylate (acrylic), and dust from various materials such as silica.   Except for exposure to infectious disease, where the effects typically present with symptoms shortly after exposure, effects of the exposure to chemicals and dusts, symptoms may not manifest for many years.  The need for improved ventilation in dental facilities goes beyond COVID-19 and is a positive step in ensuring the health of dental professionals.  Let’s look at what the CDC and OSHA recommend, starting with some key terms related to indoor air quality. The CDC guidelines state that ventilation is defined in several with respect to buildings: Indoor air movement and dilution of viral particles through mechanical or non-mechanical means Filtration through central heating, ventilation, and air conditioning (HVAC) systems and/or in-room air cleaners (portable or permanently mounted) Air treatment with Ultraviolet Germicidal Irradiation (UVGI) systems (also called Germicidal Ultraviolet or GUV) Ventilation is important to the health of dental teams and patients since airborne infectious agents spread more easily in indoor settings than outdoors, due to the higher concentrations of the viral particles indoors.   Maintenance of HVAC systems is not always top of mind in buildings unless there are issues with regulating the temperature of the buildings.   Regular maintenance, including filter changes according to the manufacturer’s instructions, upgrading the types of filters, and making sure that the filters fit properly so that as little air as possible gets around the edges of the filter. The CDC also recommends a “layered” approach to improving air quality, with includes other strategies.   More on that later… Air Exchanges Air exchange is defined as the number of times the air gets replaced in each room per hour or ACH.   Ideally the indoor air is exchanged with outdoor or “fresh” air, filtered air, or a combination of both.  According to the American Society for Refrigerating, Heating and Air Conditioning Engineers (ASHRAE), buildings should have a minimum of 5 ACH, but higher is better.   The ACH is controlled by the HVAC system in the facility, and the other types of filtrations that have been implemented in the facility.   An HVAC technician can advise a building owner or tenant about the system and its capabilities, and on modifications that can be made to meet this goal. MERV and HEPA: ASHRAE developed a rating system for air filters in HVAC systems using Minimum Efficiency Reporting Values or MERVs, that refer to a filter's ability to capture larger particles between 0.3 and 10 microns (µm).  The higher the MERV rating, the better the filter is at trapping certain types of particles.  HEPA stands for High Efficiency Particulate Air filter.   It is a pleated type of filter used in many HVAC systems and air purifiers, such as those that were installed in treatment rooms in dental facilities during the pandemic.   According to the Environmental Protection Agency (EPA) this type of air filter can theoretically remove at least 99.97% of dust, pollen, mold, bacteria, and any airborne particles with a size of 0.3 microns (µm).  Using air purifiers with HEPA filtration has been recommended by the CDC for reducing the airborne pathogens in healthcare facilities, such as dental offices, where AGPs are being performed.   MERV ratings for HVAC filters and HEPA filtration work together to establish the layered approach to ensuring enhanced indoor air quality in dental offices.    There are also ultraviolet light filtration systems that can be installed in dental facilities.   These systems, called UVGI or Upper-room Ultraviolet Germicidal Irradiation are very effective at removing air contaminants, including infectious aerosols.   Although they are used primarily in hospital settings, they can be effectively used in dental office facilities. To reiterate, just because the pandemic health emergency is over, COVID-19 is still present, as are many other airborne transmissible diseases and chemical hazards that can pose a threat to dental team members and patients.  Until COVID-19, which had such an impact on dentistry and the entire population, air quality was not a major area of concern in dentistry.   The pandemic has hopefully changed this forever.   It’s not just the airborne bacteria or viruses that can affect dental professionals.   Dust, chemicals, and other volatile organic compounds contribute to indoor air pollution that can cause health issues for the members of our profession.   This is not a new issue in dentistry, just more highly scrutinized by the high level of infectiousness of COVID-19.  In 1994, the EPA, American Lung Association, Consumer Product Safety Commission, and the American Medical Association published a booklet called “Indoor Air Pollution: A Guide for Health Professionals” as to aid in diagnosing health issues caused by exposure to airborne particles in indoor air.    So, what are the takeaways from these updated CDC guidelines?  Follow the CDC and ASHRAE guidelines for enhanced ventilation in your facility.   Remember that infection prevention and control isn’t just about surface, instrument, or equipment contamination.  Threats are always in the air – pandemic or no pandemic.  In addition, safety in the dental office includes the potential for exposure to other harmful substances in the air, such as chemicals. Develop a protocol for indoor air quality, which includes regular maintenance of the HVAC system, utilizing HEPA air purifiers in treatment rooms, opening windows periodically (if possible) to increase fresh air exchanges.  Continue to use high-volume evacuation for all AGPs – especially the use of ultrasonic scalers, which create the most aerosol.  In addition, the CDC and ASHRAE also recommend setting your HVAC system to “on” instead of “auto” to keep the fan circulating all the time.    Creating a healthier work environment is always a good plan of action for dental teams.   It helps to ensure career longevity for the team and a safer environment for patients as well.   CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, May 8, 2023 https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html  CDC Improving Ventilation in Buildings, May 11, 2023 https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/improving-ventilation-in-buildings.html  CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, May 8, 2023 https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html OSHA Subpart U – COVID-19 Emergency Temporary Standard 4 (b) https://www.osha.gov/sites/default/files/covid-19-healthcare-ets-reg-text.pdf  ASHRAE – Core Recommendations for Reducing Airborne Infectious Aerosol Exposure https://www.ashrae.org/file%20library/technical%20resources/covid-19/core-recommendations-for-reducing-airborne-infectious-aerosol-exposure.pdf  EPA – What is UVGI?  https://www.epa.gov/coronavirus/what-upper-room-ultraviolet-germicidal-irradiation-uvgi-what-hvac-uvgi-can-either-be  Indoor Air Pollution: A Guide for Health Professionals, EPA, ALA, CPSC, AMA - https://www.epa.gov/sites/default/files/2015-01/documents/indoor_air_pollution.pdf

Selecting appropriate surface disinfectants for equipment and other surfaces in the dental treatment room can be confusing.  Practices frequently receive marketing information about new products, existing products with new features, as well as product recommendations for the use of “natural” disinfectants from internet sources.   This article will examine the agencies that determine the efficacy of disinfectants and why those regulations must be followed.   It will also discuss recommendations from the Centers for Disease Control and Prevention (CDC) for products appropriate for dental settings, and other characteristics to consider when selecting the product(s) that are used in a dental practice. Regulatory Framework: It is important to know what to use for disinfecting surfaces and equipment, but even more important is why is that product acceptable.  The overall authority for approval of chemical germicides comes from the Federal Insecticide, Fungicide and Rodenticide Act (FIFRA).   Under this set of rules any substance or mixture of substances indented to prevent, destroy, repel or mitigate any pest (including microorganisms but excluding those in or on living humans or animals) must be registered with the Environmental Protection Agency (EPA) before sale or distribution.   Specific data about the safety and effectiveness of each product must be submitted to the EPA in order to obtain a registration.  Prior to submitting the data to the EPA, manufacturers must test their formulations for activity, stability, and toxicity to animals and humans, along with proposed labeling for the products.  Once the EPA concludes that the data shows that the product can be used without causing “unreasonable adverse effects”, the product and its labeling are registered with the EPA and manufacturers can sell and distribute their product(s) within the U.S.    The EPA labeling must also include “directions for use”, such as any dilution needed, contact time for specific microorganisms, method of application (spray or wipe) and other information that may be conditions for misuse of the product., Although not as commonly used currently, liquid chemical sterilants (cold sterile solutions), now referred to as high level disinfectants (HLDs) used for medical and dental devices, are regulated by the Food and Drug Administration (FDA).  In the Bloodborne Pathogens Standard, OSHA requires the use of EPA-registered disinfectants.   This requirement is for the use of a tuberculocidal disinfectant, to ensure that not only hepatitis B and HIV will be controlled, but other microorganisms more resistant microorganisms as well.  More about this later… The CDC Guidelines for Infection Control in Dental Health Care Settings – 2003 state that “when the item is visibly contaminated with blood or other potentially infectious materials (OPIM), and EPA-registered hospital disinfectant with a tuberculocidal claim (i.e., intermediate-level disinfectant) should be used.   Some confusion occurred during the COVID-19 pandemic, when the EPA was advising healthcare facilities to use a disinfectant that was proven to kill the SARS-CoV-2 (COVID) virus.   If a product was registered with the EPA and proven effective against SARS-CoV-2 (emerging pathogens), but did not include a label claim as tuberculocidal, dental practices did not meet the OSHA requirements or CDC recommendations.  How do dental teams know if their products are tuberculocidal or capable of killing COVID-19?   The answer is in the EPA’s listing of registered disinfectants.  https://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants .   The products that are registered with the EPA for claims against Mycobacterium tuberculosis (TB) are included on list B: https://www.epa.gov/pesticide-registration/list-b-antimicrobial-products-registered-epa-claims-against-mycobacterium .   Products that are registered with the EPA for claims against SARS-CoV-2 are included on list N: https://www.epa.gov/coronavirus/about-list-n-disinfectants-coronavirus-covid-19-0 . Tuberculocidal products with the label claim against SARS-CoV-2 will be included on both lists.   Again, to be OSHA compliant and follow CDC guidelines, a product must be included on list B. Reading the product label can also be helpful in making the determination about whether the product is acceptable for use in a dental practice.   If the product is registered as tuberculocidal, it will be listed on the label.     Many dental professionals were concerned about using a product that did not claim to kill COVID-19 in the early days of the pandemic.   Because SARS-CoV-2 was then an emerging pathogen, product manufacturers were required to submit testing and other documentation to the EPA in order to make this claim.   Some manufacturers were very quick to do this, and others took longer.   The manufacturers of some products that were approved to make this claim in some cases led dental professionals to believe that the products that that were currently using were unacceptable.   The reality was that the current products, registered as tuberculocidal capable of killing COVID-19, since they have been proven to kill tb, which is much more difficult to kill than SARS-CoV-2.   Coronaviruses are not highly resistant to antimicrobials or disinfectants but tb bacteria are.   In dentistry, we use the tuberculocidal kill claim as the benchmark for the efficacy of disinfectants against a broad spectrum of microorganisms. Narrowing the selection of appropriate surface disinfectants: Armed with the knowledge of what category of product(s) to use to meet regulatory requirements, dental professionals then need to determine a number of other characteristics to select the disinfectant that best meets the needs of their practice. Contact time: Contact time is defined as the length of time that a surface needs to stay wet with the disinfectant to kill the microorganisms.   This will vary by product and some products may list several contact times that are required for specific microorganisms.   For example, a 1- minute contact time may be required for HIV or SARS-CoV-2, while a 3- minute contact time may be required for tb.   Which contact time to use?   Always use the contact time for Mycobacterium tuberculosis.   Obviously shorter contact times are desired for efficiency, but users must always check the label and/or product instructions for use to determine the tuberculocidal contact time.   Again, this is not because of the prevalence of tb bacteria, but has to do the ability of a tuberculocidal disinfectant to kill more types of microorganisms and more resistant microorganisms. Product Delivery and Application System: Disinfectants come in several forms, the most common being a spray formula in a spray bottle.   These products are applied to surfaces or equipment using a spray-wipe-spray technique.  This means that the surface is applied by spraying and then wiping the surface with a paper towel or gauze (3x3” or 4x4”).   Once cleaned, the surface is sprayed again to re-wet the surface and allowed to sit for the required contact time.    Pre-saturated, disinfectant wipes are becoming more popular in dental practices because of the convenience and safety.   The National Institute for Occupational Safety and Health (NIOSH), part of the CDC; and OSHA have published information regarding the use of spray cleaners and disinfectants and the incidence of asthma among health care workers. iv   In addition, several states, including MA have developed educational materials regarding spraying of cleaning/disinfecting products at work. In addition, the CDC advises against pouring disinfecting solutions over gauze in a container to pre-wet them for use, which is described by the EPA as an “off label use” of the product.   This practice can inactivate the active ingredients in the disinfectant, rendering it ineffective. Compatibility with materials and equipment when selecting appropriate surface disinfectants: An important consideration in selecting appropriate surface disinfectants after making sure it meets the effectiveness criteria, is whether the product will be compatible with the surfaces and equipment that the product will be utilized on in the practice.   Many products contain varying levels of alcohol, which can produce drying on some treatment room surfaces.   This is especially true of chair and stool upholstery.   Always check the equipment manufacturer’s instructions for cleaning and disinfecting.   Most manufacturers make specific recommendations regarding the disinfectant formula or brand.   Other equipment, such as bracket trays, x-ray heads, and other plastics or metals will also list recommendations for the use of disinfectants or covering with barriers to avoid contamination. Some dental teams find that some disinfectants stain or leave a film build-up on surfaces, and others cite the strong scent of the product as negative characteristics. When switching from one disinfectant product to another, always clean all surfaces with warm soapy water (Dawn dish soap works well) prior to using the new product. This will prevent staining and odors from mixing of different chemicals in the products.  The EPA states that disinfectants of two different types should not be mixed together – as some dental professionals believe that it enhances effectiveness.   This can create a chemical hazard for the users.  Also keep in mind that even though a product may come in a spray and a wipe form, the chemistries for those two like-branded products are actually different and should not be mixed on the same surfaces.  For example, some dental professionals use a wipe for cleaning surfaces and then use a spray for the disinfecting process.   This is not recommended by the EPA or the product manufacturers. Another issue that dental teams contend with is the cost of the disinfecting products that they purchase.   In some cases, it may save some money to utilize one of the house brands while selecting appropriate surface disinfectants.   In some cases, the product may actually be a brand name product that has been privately labeled for the distributor.    One can determine if the products are the same by the EPA registration number on the product label. The Bottom Line: Selecting appropriate surface disinfectants is an important component of a practice’s infection prevention and control program.   Always consult the product manufacturer’s instructions for use and read the product label to determine whether the product is suitable for consideration for use in your practice. 1) Centers for Disease Control and Prevention – The Regulatory Framework for Disinfectants and Sterilants (2008), 2) Environmental Protection Agency – Pesticide Registration Manual    Accessed 4/14/2023. 3) OSHA Standard Interpretations, September 4, 1996.  Accessed 4/14/2023. 4) OSHA and NIOSH Infosheet – Protecting Workers Who Use Cleaning Chemicals -   Accessed 4/14/2023 5) MA Dept. of Public Health Occupational Health Surveillance Program https://www.mass.gov/doc/asthma-and-cleaning-products-at-work-english-0/download Accessed 4/14/2023. 6) Occupational Health Branch CA Dept. of Public Health – Cleaning Products and Work-Related Asthma  Accessed 4/14/2023. 7) CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities  (2008) Updated (2020

As we collectively let out a sigh of relief that the COVID-19 pandemic is nearing it’s end in May, it may be tempting to think about infection prevention and control as returning to the pre-pandemic practices and levels of awareness about infectious disease outbreaks.  If the pandemic has taught us anything, it is that dental professionals are more vulnerable than we previously acknowledged.   In the U.S., we are currently experiencing several significant infectious disease outbreaks that should be of concern to dental professionals.  This article will explore the three most current infectious disease issues in dentistry and how they affect the field. MEASLES:  On March 7, 2023, the Centers for Disease Control and Prevention issued a health alert regarding a measles outbreak in Kentucky.  According to this report, a confirmed case if measles was identified in an unvaccinated individual who attended a large religious gathering at a university in KY, with an estimated 20,000 people in attendance.   An undetermined number of people may have been exposed, who attended the gathering from other states in the U.S, as well as other countries. Measles can cause serious or severe health complications in both children and adults.   These can include pneumonia, and encephalitis and even death.   Since there are large numbers if individuals who are unvaccinated for measles, or whose immune status may not be adequate to prevent infection, the CDC has issued this alert to inform anyone in attendance that they may be at risk of exposure.    Measles is very easily spread through respiratory droplets, and infected individuals may be infectious to others for 2-4 days before the onset of the rash which is most characteristic of measles.   Fever and respiratory symptoms and conjunctivitis typically precede the rash, and might be mistaken for other respiratory illness. Since measles could easily spread in dental practices, it is critical to remember that screening patients for respiratory symptoms and fevers needs to be a continuing infection prevention protocol, even after the end of the COVID-19 pandemic.  Additional information about measles infections is available on the CDC website.   The CDC lists the measles vaccine (MMR), or Measles, Mumps, and Rubella; as a recommended vaccine for health care workers. An intraoral sign of measles, known as Koplik Spots, may be present in individuals who are infected, but do not yet present with the typical Measles rash.  These tiny white spots in the mouth may appear 2-3 days after respiratory symptoms appear.  They may detected in patients during treatment, and clinicians should be aware of the potential for this patient to be infectious for measles.   If the patient indicates that they have experienced respiratory symptoms, fever or itchy watery eyes in the 2-3 days prior to their dental visit, clinicians should postpone treatment, especially any treatment that includes aerosol generating procedures (AGPs). Any members of the dental team who may have been exposed and are experiencing symptoms should not be permitted to work until a diagnosis has been obtained and/or their symptoms have subsided and a medical professional has cleared them to return to work.   The CDC has several resources available for healthcare professionals to help guide the decision-making process if a measles exposure is suspected.   Fig. 1 is an excerpt from the CDC Infection Control Guidelines for Dental Healthcare Settings 2003, pgs. 8 and 9.  This chart lists work restrictions for infectious diseases and current infectious disease issues in dentistry (except COVID-19).  It is available from the CDC website:  https://www.cdc.gov/mmwr/pdf/rr/rr5217.pdf NOROVIRUS as one of the Current Infectious Disease Issues in Dentistry: Norovirus infections are commonly referred to as “the stomach flu” or a “stomach bug”. The CDC describes it as a very contagious virus that causes vomiting and diarrhea and that people infected with norovirus can shed billions of norovirus particles.   It is the leading cause of vomiting and diarrhea from acute gastroenteritis among people of all ages in the U.S.  Norovirus can be transmitted through direct contact with an infected person, consuming contaminated food or water, or touching contaminated surfaces and putting unwashed hands in the mouth.  The most recent norovirus outbreak is a multi-state outbreak traced to consumption of raw oysters.    A recent study from the National Institutes of Health (NIH) discovered that norovirus and other enteric/gastrointestinal viruses can be spread through saliva.  Therefore, contact with an infected patient’s saliva is a potential risk of exposure for dental clinicians.   While most patients would not present for treatment when they are in the acute phase of the illness, those patients remain infectious for 2-3 days after their symptoms subside.  The study indicates that these viruses can spread from coughing, and sneezing and other activities that include exposure to an infected patient’s saliva. This reinforces the need for always following standard precautions, assuming that all patients are potentially infectious. SHIGELLA/SHIGELLOSIS among Current Infectious Disease Issues in Dentistry: Shigella is a bacterium that causes an infection called Shigellosis, causing diarrhea, and which can easily spread from person to person. On Feb. 24, 2023, the CDC issued an alert through its Health Alert Network (HAN) warning that increased reports of extensively drug-resistant (XDR) cases of Shigellosis are occurring in the U.S.  According to the CDC, it takes only a small number of bacteria to cause and infection, with symptoms starting 1-2 days after exposure and lasting for 7 days.   Infected patients can spread the bacteria through their feces for several weeks after their symptoms are resolved.    The infection is caused by swallowing the bacteria.  This happens from touching contaminated surfaces with hands and touching the mouth, changing diapers of children with Shigella, eating food prepared by a individual with a Shigella infection, swallowing water when swimming, swallowing contaminated drinking water and it can also be transmitted through exposure to feces through sexual contact. While a Shigella infection is most likely to occur outside of a dental facility, both patients and team members can be potentially infectious in the office if proper attention is not paid to handwashing, wearing appropriate PPE, and cleaning and disinfecting of restroom facilities in the dental office. So, what does all this mean for dental practices?   First, we need to continue to screen patients for respiratory symptoms and be prepared to reappoint patients for non-emergency treatment.   This screening can be easily accomplished electronically when confirming patients.   Although the recommendation from the CDC in the height of the pandemic was to take patient temperatures upon arrival at the office, taking temperatures should still take place in the treatment room, as part of routine collection of vital signs.  If a patient’s temperature is above 100°F, additional screening should take place prior to treatment, since a low grade fever is often the first sign of an infection. The risk of exposure to aerosols in dentistry is not going away with the COVID-19 pandemic.   Wearing N95 respirators or higher ASTM level masks that have fewer gaps on the face continues to be an important infection prevention protocol for dental clinicians.   Cleaning and disinfecting treatment rooms as well as public areas of the facility, such as restrooms, is also of critical importance.   An excellent tool for reviewing the amount of cross-contamination that occurs in dental treatment rooms is the newly update video “If Saliva Were Red”, from the Organization for Safety Asepsis and Prevention (OSAP).  This video is available to any dental professional at no cost, and can be viewed on You Tube at:  The bottom line Dental practices must also ensure that all team members are appropriately trained to understand the principles of infection prevention and control, as well as the reasons why certain protocols must be followed.   As an increasing number of dental assistants, both clinical and administrative, are being hired into practices with no prior experience in dentistry or healthcare, this becomes more important than ever. In addition, dental practices must be aware of local and state public health regulations and recommendations, based on diseases that may be spreading in a given area.   Since many state dental boards are now requiring compliance with CDC guidelines, every practice needs to be aware of these requirements.   OSHA uses CDC guidelines for enforcement of infection control regulations and OSHA is instituting changes to their enforcement guidelines that will “hold employers to greater account for safety, health failures”. Creating the safest environment for patient care and for employees that deliver the patient care should be a priority in every dental practice, from both a legal and ethical perspective. It should be viewed as a very positive way to attract and retain patients and employees. CDC Health Alert Network (HAN) Measles Exposure at a Large Gathering in Kentucky February 2023 and Global Measles Outbreaks CDC Measles (Rubeola)  CDC Recommended Vaccines for Healthcare Workers NIH Scientists Discover Norovirus and Other “Stomach Viruses” Can Spread Through Saliva CDC Shigella-Shigellosis  CDC HAN Increase in Extensively Drug-Resistant Shigellosis in the United States OSHA News Release Jan. 26, 2023, https://www.osha.gov/news/newsreleases/national/01262023- 0

Mary Govoni, CDA, RDH, MBA, Mary Govoni & Associates So much has happened around current state of infection prevention and other areas of health care over the course of the last 3 years.   At times the change has been dizzying, confusing and frustrating.   Many dental team members are expressing their sentiments about COVID-19 fatigue.   The most common comment I hear is “I’m so tired of COVID”, and I am as well.  The reality is, however, that the pandemic still isn’t over.  On Jan. 31st President Biden disclosed that he will end the national emergency declaration related to COVID-19 on May 11, 2023.   Does this mean that the pandemic is over?  What, if anything, will be impacted in dental practices relative to COVID-19 guidance and protocols? It is important to note that although the current state of infection prevention is to end the national medical emergency declaration in May 2023, the CDC, and World Health Organization (WHO) may not end the declaration of a global pandemic of COVID-19 if cases are still spreading.  This action does, however, indicate that the crisis era of the pandemic is over – not that COVID-19 is gone from our lives.   In fact, what the CDC and other public health agencies have stated is that COVID-19 is beginning to enter the endemic stage of the spread of the disease, meaning that it will likely be always present at some level, like influenza.  This means that COVID-19, like influenza, will always present some level of risk of transmission in dentistry during aerosol generating procedures (AGP’s). In some states, under this emergency declaration, some dentists and hygienists have been allowed to administer COVID-19 vaccines to patients, which will most likely end.  But our IPAC protocols should continue to be followed, until further updates from the CDC.    COVID-19 cases continue to spread across the country.  New Omicron subvariants have been identified and now make up most of the COVID-19 cases in the U.S.   It is important to note that these variants are vaccine evasive, resulting in both vaccinated and unvaccinated individuals being infected with the virus. The CDC continues to urge health care facilities to follow their guidance for COVID-19, which includes both patient and health care worker protections thanks to current state of infection prevention. These viral outbreaks have been complicated over the last few months by a surge in cases of influenza that is higher than in recent years.   In addition, the respiratory syncytial virus (RSV) has also surged, especially in young children.  These viruses, and others, such as measles, can be spread through respiratory secretions, which puts dental professionals at risk of infections during AGP’s.   As a reminder, AGP’s are defined by OSHA and the CDC as the use of a high-speed handpiece, air/water syringe, ultrasonic scaler, air polisher and air abrasion.   Although the number of cases of COVID-19, Flu, and RSV are now decreasing, the risks of exposure for dental professionals performing AGP’s is still present.  To minimize the risk of exposure, dental professionals must still follow CDC and OSHA interim guidance, public health regulations and state dental board rules for infection control and especially for utilizing the correct PPE for these procedures. A recent study conducted at the Harvard School of Dental Medicine and published in JAMA Network,, concluded that there was no increased risk for dental practitioners contracting COVID-19 during clinical activities.  The article was cited by many groups within dentistry, but the tag line used for the citations did not include one very important conclusion from the study, which was that the study participants were wearing recommended PPE, including N-95 respirators.   On the surface, it might appear that the study concluded that the risk to dental professionals was minimal, when in fact it was and is not – for professionals not wearing the correct PPE and for those dental practices that are not continuing to screen patients for respiratory symptoms of COVID-19 and other infectious respiratory viruses.   Another issue that has come to light again in dentistry is that of contaminated dental unit water.   In 2015 and 2018 outbreaks of bacterial infections in pediatric patients who received pulpotomies in practices in Georgia and California, respectively.  These outbreaks drew attention to the need for proper testing and maintenance of dental unit waterlines to prevent infectious disease transmission.  In Oct. 2022, the CDC issued a warning through its Health Alert Network (HAN) that another outbreak had been reported. Although it is a common practice in dental facilities to treat the dental unit waterlines with some type of antimicrobial agent, to reduce the formation of biofilm and microbial growth in the waterlines, it is not as common for dental practice to test their water quality for contamination.   Testing is the only way for a dental team to know if their dental treatment water meets the CDC guideline of <500CFU/ml.  Every practice should have a waterline protocol in place that includes baseline testing of the water that is going into the unit, regular cleaning/maintenance with an antimicrobial agent, shocking the lines to remove residual biofilm and testing.  There are readily available resources for dental practices for water testing, both in-office and mail in services.  The CDC suggests that testing be performed at least quarterly. Many times, dental team members question the need to follow CDC guidance, since the CDC is not a regulatory agency, such as OSHA. The reality is, however, that most states require compliance with CDC guidelines in their dental rules.   And public health departments also require compliance with CDC guidance during current state of infection prevention.  Even in our collective state of COVID fatigue, we have the responsibility to protect the health of our patients and of course, ourselves.   Viewing CDC guidance as a burden or a nuisance, or simply a recommendation, can distort our thinking, and allow us to forget that responsibility.  Patient and health care worker safety is our primary obligation as health care professionals. Having said all that, we must always look at the practical side of compliance with regulations and guidelines.   This begins with training of dental team members to understand what is require and why it is so important.  According to OSHA and the CDC, new employees must be trained at the start of employment, which is often overlooked, as many dental practices do not have a formal onboarding process for new employees.  This is even more critical now due to a shortage of dental health care workers, and especially those with some prior experience in dentistry.   If new procedures or products are implemented or introduced into a practice, training must be provided to the team and annual training updates must be provided.  Training and retraining of team members, aids in ensuring consistency in how effectively infection prevention protocols are followed, thus increasing both patient and worker safety. Competency evaluations are an excellent tool for assessing the effectiveness of training.  This is especially important in the case of new and inexperienced team members, with no dental experience.  Can the new employees demonstrate how to appropriately reprocess instruments or turn over treatment rooms, following cleaning and disinfecting protocols?  And is there an Infection Control Coordinator appointed in the practice that can monitor that protocols are followed? A discussion of current state of infection prevention and its effect on dental practices would not be complete without addressing the issue of the financial impact on the practice.   Additional PPE, which has increased in price during the pandemic, is a key factor.  This leads some team members to consider how to cut costs with respect to infection control, such as reusing disposable items and some PPE – like face masks.   There are many areas where cost-savings can be implemented in dental practice, but cutting back on, or cutting corners is a slippery and dangers path for dental professionals.   Think of your safety, that of your patients and family members and strive to always do the right thing.  1. Centers for Disease Control and Prevention – COVID Data Tracker https://covid.cdc.gov/covid-data-tracker/#datatracker-home  (Accessed 1/31/23)  2. Centers for Disease Control and Prevention – COVID-19 Variants  https://www.cdc.gov/coronavirus/2019-ncov/variants/index.html?s_cid=11720:covid%2019%20variants%20of%20concern:sem.ga:p:RG:GM:gen:PTN:FY22 (Accessed 1/31/23) 3. Centers for Disease Control and Prevention – Interim Guidance for Healthcare Personnel - Potential Exposure at Work – updated 9/23/22  https://www.google.com/search?q=cdc+guidance+for+healthcare+workers&rlz=1C1CHBF_enUS1016US1016&oq=CDC+guidance&aqs=chrome.2.69i59j69i57j35i39j0i512l4j69i60.4783j0j4&sourceid=chrome&ie=UTF-8  (Accessed 1/31/23) 4. Centers for Disease Control and Prevention – Infection Control Guidance – updated 9/23/22  https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html (Accessed 1/31/23) 5. Centers for Disease Control and Prevention Flu Activity & Surveillance Data https://www.cdc.gov/flu/weekly/fluactivitysurv.htm  (Accessed 1/31/23) 6. Centers for Disease Control and Prevention Respiratory Syncytial Virus (RSV)  https://www.cdc.gov/rsv/index.html  (Accessed 1/31/23) 7. Centers for Disease Control and Prevention - The National Respiratory and Enteric Virus Surveillance System (NREVSS) https://www.cdc.gov/surveillance/nrevss/index.html (Accessed 1/31/23) 8. Centers for Disease Control and Prevention – Infection Control Guidance – updated 9/23/22  https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html (Accessed 1/31/23) 9. Harvard School of Dental Medicine – Study Shows Dental Practitioners Did Not Face and Increased Risk of Contracting COVID-19 During Clinical Activities https://hsdm.harvard.edu/news/study-shows-dental-practitioners-did-not-face-increased-risk-contracting-covid-19-during#:~:text=Study%20Shows%20Dental%20Practitioners%20Did,Harvard%20School%20of%20Dental%20Medicine (Accessed 1/31/23) 10. Jama Network – Evaluation fo Comprehensive COVID-19 Testing Program Outcomes in a US Dental Clinical Care Academic Setting, Dec. 13, 2022 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2799439 (Acessed 1/31/23) 11. Mycobacterium abscessus Infections Among Patients of a Pediatric Dentistry Practice — Georgia, 2015. MMWR Morb Mortal Wkly Rep 2016;65:355–356. DOI: http://dx.doi.org/10.15585/mmwr.mm6513a5 (Accessed 1/31/23) 12. Hatzenbuehler LA, Tobin-D’Angelo M, Drenzek C, et al. Pediatric Dental Clinic-Associated Outbreak of Mycobacterium abscessus Infection. J Pediatric Infect Dis Soc. 2017 Sep 1;6(3):e116-e122. https://pubmed.ncbi.nlm.nih.gov/28903524/ 13. CDC Health Alert Network - Outbreaks of Nontuberculous Mycobacteria Infections Highlight Importance of Maintaining and Monitoring Dental Waterlines https://emergency.cdc.gov/han/2022/han00478.asp (Accessed 1/31/23) 14. CDC Division of Oral Health – Dental Unit Water Quality https://www.cdc.gov/oralhealth/infectioncontrol/faqs/dental-unit-water-quality.html (Accessed 1/31/23)

Staying informed and up-to-date on the latest news and developments in the dental industry is essential for us. One way to do this is by listening to the Compliance Divas podcasts that focus on important topics such as dental infection prevention and control. These podcasts provide valuable information and insights on how to maintain a safe and compliant dental practice software by following dental infection control protocols. In this article, we will share one of their top podcasts that covers the topic of infection statistics and control at the beginning of 2023. You can listen to it here: Here are the main thoughts and important statistics discussed in the episode: "As the new year begins, we are reminded of the ongoing challenges in infection prevention and control. These challenges have been exacerbated by the emergence of new variants of the coronavirus. In this episode, the Divas delve into some of the most pressing issues related to infection prevention and control, including the impact of these new variants and the measures that can be taken to mitigate their spread. As we move forward in the new year, it is crucial that we remain vigilant and proactive in our efforts to prevent the spread of infection and protect public health. The CDC reports that seasonal influenza activity is declining in most areas, but 61 pediatric deaths have been reported this season. Overall, there have been 20 million illnesses, 210,000 hospitalizations, and 13,000 deaths from the flu. The new Omicron sub-variant, XBB 1.5, is a concern as it is more infectious and evasive to vaccines. The CDC estimates that 40% of confirmed COVID cases are from this strain, so be aware of symptoms such as sore throat, hoarseness, cough, fatigue, nasal congestion, runny nose, headache, and muscle aches. The number of invasive group A strep infections, primarily in children, is increasing. These infections can lead to severe conditions such as necrotizing fasciitis (flesh eating disease), toxic shock syndrome, and cellulitis. Historically, strep was considered a minor illness treated with antibiotics, but now dental practices must take precautions to prevent spread of the disease by refusing treatment for children with symptoms despite having PPE on dental professionals. The recent study by Harvard School of Dental Medicine titled "Dentists and Covid Risks: No Increased Risk for Dental Practitioners During Clinical Activities" has been widely cited by various organizations such as the American Dental Association and American Hygienist Association. However, it is important to note that the study's conclusion that there is no increased risk for dental practitioners during clinical activities is misleading. The study found no cases of Covid among dental students at Harvard due to the use of N95 respirators and other appropriate personal protective equipment. The study also did not have a control group for comparison. Therefore, it is important to read the study in its entirety and not rely solely on the headline before drawing conclusions. Therefore, it is crucial to wear the appropriate PPE to protect from various respiratory illnesses, including COVID-19. Standard precautions should always be followed and using N 95 respirators should not be dismissed. Resources: CDC Flu Activity and Surveillance - https://www.cdc.gov/flu/weekly/fluactivitysurv.htm CDC Respiratory Syncytial Virus Infection (RSV) https://www.cdc.gov/rsv/index.html CDC Covid Data Tracker https://covid.cdc.gov/covid-data-tracker/#datatracker-home CDC COVID-19 Variant Information https://www.cdc.gov/coronavirus/2019-ncov/variants/index.html?s_cid=11720:variants%20of%20covid%20virus:sem.ga:p:RG:GM:gen:PTN:FY22 https://www.buzzsprout.com/1774326/11993585-86-updates-on-infection-control-covid-19-sub-variants-rsv-influenza-and-more "

Questions about testing dental waterlines are all over social and print media. Terms like DUWLs, CFUs, and LPSs are in the literature but what does that alphabet soup mean and what is a dental office supposed to do about it? The good news is, is it isn’t as hard at pronouncing words like Pseudomonas Aeruginosa (which is something could be hanging out in your dental unit waterline, DUWL, right now). So let’s get you on a path to clean waterlines and keep you off the latest news cycle. It’s really a simple 5 step process to make sure waterlines are in the clear. 1. Shock: First you have to shock all your dental unit waterlines. When I say all, I mean ALL! Even the ones you don’t use--actually, especially the ones use--they are the most likely to have built up biofilm due to the stagnant nature of the line. You can use a diluted bleach solution or a prepared shock solution. There are many articles and videos online for the exact instructions on how to shock based on the method you choose. 2. Test: After you shock you need to determine if your lines contain less than 500 colony forming units (CFUs). There are a few options out there for testing. You can do it yourself with an in-office test such as ProEdge Dental’s QuickPass or Aquasafe water test kits. They are both easy to use. The QuickPass has a 48-72 hours incubation period, while the Aquasafe requires 7 days. Or you can outsource and send samples out to a lab. Once again, when you test you have to test ALL of your lines. So that could mean water samples from 3-7 lines per operatory--don’t forget your ultrasonic scaler, it has a waterline too. If you don’t pass the test, go back to step one and shock again. 3. Treat: Now that you have determined your lines are safe, let’s keep them that way. You can treat them daily with a tablet-like BluTab or you can install a straw into your unit water reservoir that is replaced yearly. Do not be fooled by a well-meaning rep that tells you the tabs or straw are all you need to do. Unfortunately, if you aren’t doing step four the biofilm will build right back up. 4. Maintainance: Daily maintenance is key to keeping your lines free of CFUs. At the end of each workday, the lines need to be dried so that water doesn’t sit stagnate overnight or over the weekend. Standing water is a biofilms dream. Just think of a vase of flowers, after that water sits for days a film grows on top of the water and on the sides of the vase that is hard to remove. That’s a biofilm. So imagine your tiny dental waterline tubing and water sitting in it for any period of time. Here’s an example of a daily waterline routine:  Fill the unit reservoir with tap water (note distilled water will not keep you safer, in fact, it has no chlorine so you are more likely to build up biofilm)  Put in Blu Tab if using and reattach water bottle  Turn unit on  Run all lines for at least 30 seconds  Between Patients  Run all lines that enter the patient’s mouth for 20-30 seconds Turn unit off Drain water from the unit reservoir, dry Straw if using, and reattach bottle Turn unit back on and run all the lines until they are dry Turn unit off "If your ultrasonic scaler has a separate water source be sure to complete all the steps above with it." 5. Re-Test: It is key to re-test your waterlines to be sure that regrowth has not occurred. OSAP recommends that you re-test monthly at the beginning of implementing your waterline maintenance routine. If monitoring results show your water quality is acceptable for 2 consecutive months then you can move to quarterly testing. If a unit fails then you start the cycle all over again with step one and shock your lines. It is key to also be sure you are keeping records of your efforts. Dental Board inspectors are consistently asking for this documentation to ensure you are compliant. ProEdge.com has a free handy checklist you can download (link below). Or you can create your own. Just be sure you are keeping track! While this may seem like one more thing to add to our already busy routine it’s a key step to ensure you are providing a safe environment for your patients. I have had dentists push back at the cost of the tests or the time it takes to establish yet another protocol. But just imagine if your mother, grandmother, child or even you, were in that chair, wouldn’t you want to know those lines are safe? ~Amanda Hill, RDH, BSDH Disclaimer: This article is the sole opinion and research of the writer and doesn't reflect the opinions of ZenSupplies.  Resources: More references on this subject: https://osapjdics.scholasticahq.com/article/5075-dental-unit-water-quality-organization-for-safety-asepsis-and-prevention-white-paper-and-recommendations-2018 Waterline testing Log: https://proedgedental.com/wp-content/uploads/2019/05/QuickPass-Log_5.2019_V3.pdf  Some of the ABBREVIATIONS as a reference: ADA - American Dental Association ANSI - American National Standards Institute AWWA - American Water Works Association CDC - Centers for Disease Control and Prevention CFU/mL - Colony forming units per milliliter DFU - Directions for use (see also IFU) DHCP - Dental health-care personnel DUWL - Dental unit waterline EPA - US Environmental Protection Agency FDA - US Food and Drug Administration HAI - Healthcare-associated infections HPC - Heterotrophic plate count IC - Infection control (or infection prevention and control)

Dental practices have faced numerous challenges this year, due to the COVID-19 pandemic and those challenges continue.   As the number of cases of COVID-19 continues to increase, dental practices are facing additional hardships.  Supplies of PPE, especially respirators, continue to be difficult to find.  Dentistry now faces shortages of disinfectant wipes and gloves.  And as the community spread of COVID-19 increases, patients and dental team members are becoming infected in record numbers, causing confusion about what to do in case of exposure.  Yet another challenge that looms on the horizon is increased surveillance of dental practices by regulatory authorities, such as OSHA and state dental boards.   Managing these challenges requires dental teams to continue to access information updates from public health agencies, training when updates occur, and written documentation of efforts to provide the safest environment for both patients and dental teams. There have been numerous OSHA inspections in dental practices resulting from complaints from employees.  In addition, some state OSHA agencies have been conducting unannounced inspection for compliance with COVID-19 guidelines for employee safety.  In the case of a practice in MA, OSHA issued numerous citations and fines of $9500.00.   Information about this inspection is available through these links:  Inspection Detail | Occupational Safety and Health Administration (osha.gov),  and Georgetown Dentist Fined $9,500 For Violating Coronavirus Safety Guidelines – CBS Boston (cbslocal.com).  The good news is that vaccines should be available within the next few months.   It is important to note, however, that the introduction of the COVID-19 vaccines will not immediately end the pandemic.  Most public health experts agree that COVID-19 will continue to spread and require us to continue to follow our guidance from the CDC for at least the next year.   We must continue to be vigilant in screening patients and employees, wearing appropriate PPE, practicing universal source control, updating infection prevention training and documenting all of the protocols that we follow to protect both patients and dental team members. While it is unlikely that dental practices will be ordered to close again, as in the beginning of the pandemic, we cannot let pandemic fatigue to cause us to let our guard down.  Instead it is an opportunity to fine tune our protocols to be prepared for whatever may come our way.   Let us look at these protocols and what is required. Both OSHA and the CDC state that when aerosol-generating procedures are performed, the respiratory protection level is N95 or higher.  Guidance for Dental Settings | CDC and COVID-19 - Control and Prevention | Denstistry Workers and Employers | Occupational Safety and Health Administration (osha.gov).   When N95 masks were very difficult to find in the beginning of the pandemic, the FDA allowed the use of Chinese-approved KN95 respirators to be used during the pandemic through its Emergency Use Authorization (EUA) provisions.   In addition, when even the KN95 respirators were difficult to obtain, the CDC guidance stated that an ASTM Level 3 surgical mask and a full face shield could be work, but not for treating a patient that known or suspected to be COVID-19 positive.    Although N95 respirators are still not in great supply, they are available now through both dental and medical distributers.   Respirator manufacturers have increased production and shifted production to the U.S. to assist in getting these much- needed devices to health care professionals.   In addition, the FDA EUA allows health care workers to reuse these disposable (one-time use) devices to help supplies to last longer. It is risky to assume that just because respirators were difficult or impossible to obtain several months ago, that may not be the case now.   If your practice is inspected by OSHA, an inspector will ask to see documentation of your attempts to obtain appropriate PPE.  Keeping a log of these efforts will protect your practice against citations and fines. There have been news reports of severe shortages of gloves.   This could be a game changer.   Unlike respirators during the EUA, gloves cannot be reused.   Practices may have to switch from their preferred type or brand of gloves temporarily, even using latex gloves in some cases.   Latex gloves have not been used routinely for some time because of the prevalence of sensitivity and allergies on the part of patients and dental professionals.    If you must use latex gloves, be sure to screen both patients and employees for these sensitivities and make sure that your Epi-Pens are accessible and up to date in case there is an emergency. Many dental distributers are providing different brands of disinfectant wipes than what most practices are familiar with.  Make sure that the product is EPA registered, and has a label claim as a tuberculocidal disinfectant.   Although many manufacturers are promoting their EPA-registered claims against SARS-CoV2, the CDC Guidelines for Infection Control in Health-Care Settings states when there is the presence of blood, an intermediate level, tuberculocidal disinfectant must be used.   RR5217 Dental Front.pmd (cdc.gov).  The EPA stated early in the pandemic that products on the EPA List N should be used, but recently clarified that if a product does not appear on this list, but has a label claim for a microorganism more difficult to kill than SARS-CoV-2, it was acceptable to use.   List N Advanced Search Page: Disinfectants for Coronavirus (COVID-19) | Pesticide Registration | US EPA. It is possible that your favorite brand of disinfectant is available in a liquid formula that can be applied with a spray bottle, however, it is important to remember that we switched from spraying disinfectants to using wipes to decrease chemical exposure (and potential for respiratory problems) for dental team members.   The solution can be sprayed onto an applicator (gauze or paper towel) and applied to surfaces.   The CDC Guidelines for Sterilization and Disinfection in Health Care Settings  Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 (cdc.gov) state that solution should not be placed in containers where gauze or other applicators is soaked.   The fibers in the gauze will inactivate the solution.   Wipes are different in composition and do not cause this to happen.   Several companies, including SciCan, sell dry wipes (StatWipes) that you can add your preferred disinfectant to.   In addition to an OSHA-required Exposure Control (infection control) Plan, dental practices must also have a COVID-19 Preparedness and Response Plan.   This must be in writing and is a key document scrutinized in an OSHA inspection.   Key elements of this plan include a Hazard Assessment and Exposure Determination, and protocols to follow if an employee is exposed to COVID-19 at work.   Guidance for the Preparedness and Response plan is available from OSHA in these documents:  https://www.osha.gov/Publications/OSHA4045.pdf  and Guidance on Preparing Workplaces for COVID-19 (osha.gov).    CDC guidance on exposure to COVID-19 and returning to work is available in these documents: Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19 | CDC, Return-to-Work Criteria for Healthcare Workers | CDC.  When dental team members wear respirators, a written respiratory protection plan is also required, which includes information on the required medical evaluations and fit testing of the devices.   Again, OSHA has provided guidance on developing a plan in these links and documents:  https://www.osha.gov/Publications/OSHA3990.pdf,  OSHA 3384 SMALL ENTITY FOR RESPIRATORY PROTECTION STANDARD REV 9.28.11:Layout 1.   Medical evaluations and fit testing must be documented.   Although it has been reported that OSHA has suspended all fit-testing requirements, it has only suspended the annual fit-testing of respirators.   These tests must be completed initially (when first wearing respirators) and any time that the type or brand of respirator is changed.   Since this could be often, due to supply shortages, I recommend that dental practices conduct their own fit-tests.   A member of the team can be trained to administer the fit-test and test kits can be purchased through most dental distributors.   Some test kits come with an instructional video, but online training is available and there is no certification required.   A free, online program for fit-testing is available through the American Association of Occupational Health Nurses at:  AAOHN : Online Learning. Dentistry will be forever changed by this pandemic – mostly in positive ways.   We have a better understanding of disease transmission and how to control the spread of infectious diseases.   We have more scientific knowledge about the hazards of exposure to aerosols in dentistry and the importance of air quality in our dental health care settings.   Our patients have a greater appreciation for all the safety protocols we follow to keep them safe.   The negative impact is most certainly from the costs associated with PPE and other equipment and supplies.   But we are dedicated to the delivery of quality oral health care in the safest manner possible.  We will survive this challenge and quite possibly be more resilient because of it and be better prepared if another pandemic occurs in the future. If your practice would like some assistance in developing your OSHA and COVID-19 documentation, please contact me at mary@marygovoni.com,  or visit my website at www.marygovoni.com.    Mary Govoni, MBA, CDA, RDH Mary Govoni & Associates

Many are concerned with what’s next? When do we get back to normal? What is the new normal? While all of these things are important, I truly believe that the new normal is the renaissance of entrepreneurship in the dental space. Every person who is in the operatory or the front desk has an IDEA! Most importantly EVERY idea is worth putting in action. Every idea is worth exploring and giving it a try. So my question is how do we encourage and propel entrepreneurship forward at the time of uncertainty?  Just a simple observation, tough times are the best time to start a business! When I meet with doctors, hygienists, and my favorite dental assistants I encourage them to bring small, seemingly simple/ uninspiring ideas, to some sort of fruition. You gotta get it out and let the world see it. Yes, most ideas will be labeled as “stupid” but if you have what it takes you will go back and think through and come up with a new version. There has been a strong push to start service type business or consulting, to help dental practices with different aspects of collections, operations, OSHA, Compliance, HR, etc. We also see a new wave of dental assisting schools opening across the country, and I want to give a shout out to my friend John Hatfield and his business partner Amanda for opening a new type of dental assisting school, with an added emphasis on budgeting, how to order supplies and compliance.  The type of entrepreneurship I would like to encourage and support is around Product Innovation. It would be so great to encourage product type entrepreneurship. Imagine we create a world where dental professionals are encouraged to bring new, innovative ideas to life. I’ve been asking people to develop a new type of wipes that are eco-friendly, use natural ingredients, and use recycled materials. Anyone, please? So what do we need to do as an industry to help bolster entrepreneurship within the dental field? In my personal opinion few things need to be done or developed: Ecosystem for inventors to be able to quickly list a product (or products) provide a Shopify like experience and access to the audience of shoppers who can see new products and give it a try.  The ecosystem needs to truly support inventors from the bottom up. So if there is no sales at all or just a small volume, there shouldn’t be any fees associated with listing and selling products. We need to give it a push just enough for inventors to see that there is a demand. The ecosystem that provides access to end users/ buyers. If there is a demand we need to provide inventors access to people who try the product and can provide feedback, either through review, or even online conversion - could be chat or Google Meet.  Support Inventors with product distribution without any legal jargon or hard rules, or exclusive contracts. Or better yet provide a software solution for efficient drop ship (something similar to ShipStation). Providing support. It’s easy for some of us to create and invent and push forward, however after meeting so many people I realize there are a lot of people with great ideas and potentially with life-changing inventions that simply don’t believe in themselves. I also don’t believe in fake encouragement, however, the market is the market. If the product is good, people will buy it! There is really no downside in giving it a try.  Podcast Support. It’s clear that the attention is shifting from forums to Facebook Groups and Podcasts. I believe each podcast should have a spot to allow Inventors to present products at no cost. It shouldn’t be a 2-3 minute commercial. More of a story, details, and why this product is important.  This Friday I’ll be interviewing one of my good friends Dr. Matt Kathan, owner of Timber Dental, a Portland-based small DSO with 5 locations. During COVID, Dr. Matt invented a product and he will share with us what he learned. I’m really excited to discuss how we can help and support dental inventors across the US.  [embedyt] https://www.youtube.com/watch?v=rCWWEbnc-Yc[/embedyt] Tiger Safarov

Dear ZenFamily, Happy Monday and happy August to all! As we jump into another busy week, we’d like to share a recap of live events and webinars for last week (the week of July 27) as well as some exciting live events that we have planned for the week of August 3. So here goes! On Wednesday, July 29, by many requests from the ZenFamily, we invited Mary Govoni to the live webinar to discuss the new OSHA/CDC guidelines, requirements, and simply what's working and what our teams need to know about infection control. Tiger  asked Mary about the current shortage of Nitrile Gloves and Surface disinfectants (wipes). What are the options if we can't buy any more? How do we get through the tough times? Please take a look at the full webinar here: https://youtu.be/Gr2K_HEyymU And here is the podcast: https://share.transistor.fm/s/b8be1436 To find more information on Mary Govoni & Associates, please visit: On Friday, 7/31 at 11 am CST, Tiger hosted our traditional "15 min Friday Supply Availability Update" for Zen Offices! Please join us Every Friday at 11am Central for a live update on what is going on on the market and availability of dental supplies. All you have to do is login to your Zen account, app.ZenSupplies.com For the week of August 3, we have planned the following events: 1. On Wednesday, August 5 at 11 am CST, we invited John Hatfield and Amanda Newhouse to a live event to share with us what the process of opening up a dental assistant academy entails. John from Dental Assistants Worldwide will cover in depth the challenges and exciting aspects of starting the Cornerstone Dental Assistant Academy. We plan to ask John and Amanda the following: -What made him want to start a dental assisting academy? -What will be different in their school as compared to other dental assisting schools? -Why is a dental assisting academy needed? -Will Cornerstone Dental Assistant Academy provide remote learning options? -What are the challenges with the school not being remote/being remote? -How will the  curriculum change post covid? -How will the curriculum influence sedation, implants, sleep apnea procedures? How to prepare for the new trends in dentistry? The benefit of the LIVE Webinar is that we will be able to answer YOUR questions during this time. So please join us at 11 am CST on Wednesday 8/5 at 11 am CST! All you have to do is login to your Zen account, or follow this link: https://app.livewebinar.com/699-206-742 2. And per our Friday tradition, on Friday, August 7 at 11 am CST Tiger will host a 15 minute Supply Availability Update. The ZenTeam is spending countless hours every week doing due diligence, learning about different products and product shortages, and sourcing new vendors. In addition, the landscape of the supply chain is constantly changing and so are the prices of PPE products. Therefore, I would like to host a 15 min live event EVERY Friday at 11 am Central with a special guest to go over what we learn during the week. We will share EVERYTHING-good, bad and what to prepare for. And this Friday, we invited Dr. Matthew Kathan from Timber Dental to share his invention with us!  Simply login to your ZenSupplies account and join us there for all live events! Thank you to all for participating in our live events and we look forward to seeing everyone during this week’s webinars!

Dear ZenFamily, Hope everyone is staying safe and having a productive week so far! Last week here at Zen we had a webinar on Friday 5/15 on "Understanding N95/KN95 Masks and 3 Ply Surgical Masks, Compliance For Dental Practices Including research/diagrams/test/in office test log forms". Mary Govoni joined Tiger to answer questions on what products to start ordering asap, understanding the different masks types, compliance for dental offices, current market counterfeits and much more. Please find the full webinar here: https://www.youtube.com/watch?v=JdSx0fNEEvM https://open.spotify.com/episode/6ro2XbV7touiThhJc3gV05?si=XKhnHRiITMW4SIpzA5N2rg Notes and Links discussed during the webinar: *Disclaimer: all information below is only suggested and not presented as scientific research nor acts as a guideline for dental practices. This is only expression of the research we've done for our members in the attempt to consolidate different ideas in one resource. Below information is assembled by Zen Team only and not related to opinions/recommendations of guest speakers on the webinar. General Info on Mask and Identifying Counterfeit: ADA Tips to Avoid Counterfeit: https://success.ada.org/~/media/CPS/Files/COVID/ADA_TipsToAvoidCounterfeitMasks.pdf?utm_source=adaorg&utm_medium=adanews&utm_content=cv-counterfeitmask&utm_campaign=covid-19 ADA Guide on Understanding different masks: https://success.ada.org/~/media/CPS/Files/COVID/ADA_COVID19_UnderstandingMasks.pdf?utm_source=adaorg&utm_medium=adanews ADA 1 CE Course on Respiratory Protection in the Era of COVID-19 (great resource): https://success.ada.org/en/practice-management/patients/digital-events/ada-and-osap-respiratory-protection-in-the-era-of-covid-19-webinar?utm_source=adaorg&utm_medium=adanews American Association of Occupational Health Nurses Online Course: Respiratory Protection Program Training and Resources (Free Certification) - Recommended to have at least 1 team member to be Certified: http://aaohn.org/p/cm/ld/fid=1138 Level 1/2/3 3 Ply Surgical Masks: Study on effectiveness of N95 vs Surgical Masks: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868605/ Level 3 Masks are recommended for use in Dental Practices: https://healthcentricadvisors.org/wp-content/uploads/2017/04/3_MaskEnomics_Poster_2012.pdf Research from Dental Advisors from 2014 (Trying to find something more recent, if you know of a resource, please add in comments). Face Masks, What to wear and when: https://www.dentaladvisor.com/pdf-download/?pdf_url=wp-content/uploads/2015/02/face-masks-what-to-wear-and-when.pdf Choose the right mask from Cardinal Health. Visual diagram of Understanding ASTM level of Protection: https://www.cardinalhealth.com/content/dam/corp/web/documents/whitepaper/Face%20Mask%20Selection%20Guide.pdf N95 Respirators Resources: ADA Tip Sheet on identifying counterfeit N95 masks (as of May 7, 2020): https://www.ada.org/en/publications/ada-news/2020-archive/may/ada-tip-sheet-includes-cdc-guidance-on-identifying-counterfeit-n95-masks Fit Test Kit and Instructional Video (Product Available on Zen Resource Page): https://www.allegrosafety.com/product/saccharin-fit-test-kit/ How to Perform a User Seal Check with an N95 Respirator (different from Fit Test):https://youtu.be/pGXiUyAoEd8 OSHA Compliance requirement (documented on ZenResource Page as of May 7, 2020): Every Employee Must Complete - Respirator Medical Evaluation Questionnaire: https://www.osha.gov/Publications/OSHA3789info.pdf Every Employee must complete Fit Test prior to using a Respirator. ReCertification is required 1/year. Safety Fit Test Record: https://www.allegrosafety.com/wp-content/uploads/2019/10/Respirator-Fit-Test-Record.pdf List of Respirator Trusted-Source Information (From CDC Website): https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3healthcare.html#e NIOSH - Approved N95 Particulate Filtering Facepiece Respirators (Full List of Approved manufacturers): https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/N95list1.html Surgical N95 Respirators Approved Manufacture List (Short): https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3surgicaln95.html KN95 Masks Resources: NIOSH International Assessment Results - Not NIOSH approved: https://www.cdc.gov/niosh/npptl/respirators/testing/NonNIOSHresults.html List of Approved Manufacturers (FDA Approved as of May 7, 2020): www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3surgicaln95.html Steps to spot counterfeit products (these steps make assumption that documents provided are true in nature and have not been reprinted with logos of FDA/NIOSH and any other organizations): The manufacturer from who the product is manufactured should have an FDA certificate on file with their name and the approved product The manufacturer must be on the approved Chinese exporter list There should be a testing report on file that they can send to show you they are a legitimate product The distributor could or should have FDA Registration to be able to import these products. Always ask for FDA registration of the vendor who is exporting products. FDA Database of Registration & Device Listing: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRL/rl.cfm Reusable Gowns/Laundry Service and Washer/Dryer Installation: Cost of reusable gowns is between $20-$30/gown. We will work on getting a source for a group order for the reusable gowns. Cost of Pick Up and laundry service. First of all I would highly recommend to talk to your local Laundry Service provider and discuss how to work together. Prices that we found online are ranging from $.95 to $3 per pound, including pick up/drop off/folding. The other option is Washer and dryer Hookup: The cost of installation: https://www.thumbtack.com/p/washer-dryer-hookup-cost Portable washer/dryer: https://www.wayfair.com/GE-Appliances--Spacemaker%C2%AE-3.6-cu.-ft.-Portable-Dryer-DSKP333ECWW-L7322-K~GEAP1077.html?refid=GX350646125182-GEAP1077&device=c&ptid=753249148770&network=g&targetid=pla-753249148770&channel=GooglePLA&ireid=66097775&fdid=1817&gclid=EAIaIQobChMIr5rFq-O26QIVR5yzCh0z7ghOEAQYBCABEgJ67fD_BwE Here are the details on the webinar coming up for the week of 5/18: On Friday, 5/22, at 1pm CST, we invited Dr. Gina Dorfman, a dentist and fellow CEO of Yapi Dental and Julie Varney, CDA, RDA, COA, FAADOM, CDSO, CDSH, Mentor of Dental Assistants Rock to share their experiences, tips and advice on reopening your practice. Dr. Dorfman's practice reopened on Monday, 5/18 and she will share with us how her office went through the reopening process and what their quarantine experience was like. Julie is in New York and her office has not reopened yet. They've done a lot to train their staff on new updates, performed a systems check and stocked up on PPEs. Dr. Dorfman will also talk about some protocols! Be ready to ask Julie and Dr. Dorfman lots of questions and feel free to share your reopening experience with fellow Zen offices! https://livewebinar.com/892-097-831 We hope everyone is enjoying the live events! Stronger together!

Dear ZenFamily, Happy Monday to all! We hope everyone had a fun and safe weekend.  As we jump into another busy week, we’d like to share a recap of live events and webinars for the last week (the week of June 1) as well as some exciting live events  that we have planned for the week of June 8. So here goes! On Thursday, June 4th, Tiger was joined by Mike Sands, an expert in the field of fogging to discuss: Disinfecting With Cold Fogging? Does it Really Work for Dental? Currently, Mike is a partner and the VP of Marketing and New Product Development at Cloudburst, Inc. (a world leader in misting systems engineering and manufacturing). Dr. Tom Larkin introduced Tiger to Mike Sands. Here is a short description from Dr. Larkin himself: "Mike Sands is authoritative. In fact, he holds several patents and his company Cloudburst developed the first sideline misters introduced in the NFL in 1994.  They were the first misting/cooling system used in the 1996 Atlanta Olympics. Mike is a serial inventor and holds several patents in this space. I have no idea how I stumbled onto their website, but I am glad I did. I think cold fogging is an integral part of our come back protocol. Search the internet and you will see electrostatic sprayers and numerous fogging sprayers. Many, direct from China. I have been quoted as much as 30K for a system.  Mike will break it down and introduce you to a fogger for less than 50 BUCKS!  One per Op. Personal fogging protection." Here is Mike's Bio: Currently, Mike is a partner and the VP of Marketing and New Product Development at Cloudburst, Inc.  (a world leader in misting systems engineering and manufacturing).  Prior to partnering with Cloudburst, Mike was involved in several business startups and ownerships including iMist LLC. (a company specializing in the development and sales of personal - portable misting and spraying products).  He is a serial inventor with multiple patents and first to market products in his portfolio.   He loves problem solving and creating new things which have guided him along his successful entrepreneurial path.  Two of his favorite (2) word phrases are “WHAT IF” and “ WHY NOT”. Here is where you can find the full webinar: https://www.youtube.com/watch?v=QSHnJ-x91a0 Please find the podcast here: https://share.transistor.fm/s/fb31e3dc During the webinar, we covered and referenced lots of resources in regards to COVID-19 and what it means to disinfect with cold fogging. Please find them below: Information on cold fogging and the Cloudburst product: https://www.phoenixdentalproject.com/fogging Check out their YouTube channel: https://www.youtube.com/user/CloudburstMS Electrolyzed Water System, Generate Hypochlorous Acid (HOCl) Cleaner & Disinfectant: https://store.ecoloxtech.com/ecoone And on Friday, 6/5 at 11 am CST, we started a new tradition with a "15 min Friday Supply Availability Update" for Zen Offices that is hosted by Tiger! Please join us Every Friday at 11am Central for a live update on what is going on on the market and availability of dental supplies. All you have to do is login to your Zen account, app.ZenSupplies.com For the Week of June 8th, we have planned the following events: Tuesday, 6/9, we have uploaded the new Guidelines Information from the CDC: “Guidance for Dental Settings During the COVID-19 Response” where everyone will have access to CDC resources such as the webinar, slides, information for healthcare professionals and frequently asked questions for healthcare providers. This information will be available to you through the live events & webinars tab on the dashboard. Please see here for more information: https://emergency.cdc.gov/coca/calls/2020/callinfo_060320.asp Reference: Hannan, Casey, et al. “Webinar June 3, 2020 - Guidance for Dental Settings During the COVID-19 Response.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 14 Apr. 2020, emergency.cdc.gov/coca/calls/2020/callinfo_060320.asp. Thursday,6/11 at 11 am CST, Tiger will host a webinar on the “Review of Dental Catalogs and other changes on the Zen platform” as the dental catalogs were not as successful of a roll out as we had hoped. We learned our lesson and made several changes. Tiger will discuss and review these changes . We will make sure to take all the feedback from you so please come prepared with lots of questions, ideas and suggestions! We plan to cover: dental catalogs search and filters, why we changed to manufacturers, the pause on office supplies and for how long as well as upcoming dashboard changes and changes to my inventory. And of course, per our new Friday tradition, on Friday, June 12th at 11 am CST, Tiger will host a 15 minute supply availability update. Everyone is beyond ready to get back to work in a safe environment. The ZenTeam is spending countless hours every week doing due diligence, learning about FDA approvals, learning about product shortages, and sourcing new vendors. In addition, the landscape of the supply chain is constantly changing and so are the prices of PPE products. Therefore, Tiger will host a 15 min live event EVERY Friday at 11 am CST to go over what we learn during the week. We will share EVERYTHING-good, bad and what to prepare for.Simply login to your ZenSupplies account and join us there for all live events! Thank you to all for participating in our live events and we look forward to seeing everyone during this week’s webinars!