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

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)

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

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

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)

10 Things Every Assistant Should know about Infection Control: PPEs - 4 items - mask; gloves; goggles; gown Utility Gloves Transport bins - to transport our items from the operatory to the sterilization area in a closed puncture proof, leak-proof container. With a biohazard sticker. Disinfectants - 2 step or 1 step. One step or two-step and are you doing, if you're using a two-step, are you doing the true two steps. Loading Autoclave - Paper down. Plastic up. Dating Indicators on pouches - Loading the autoclave indicators, on pouches, there's external and internal. Then on the wrap, they're on paper and tape, the tape changes to stripe but we also need to put an indicator inside our cassettes. Seven, was the date your items by load date and autoclave if you have more than one. Eight was you need to weekly spore test your autoclave or whatever sterilizer you use. Then always read your IFUs, your infection, we're talking about infection control, your instructions for use on any type of product. Always read. Read. Read. Read. Ten was your annual training. Because things change, just like one of the changes last year was all handpieces that are air driven must be autoclaved, the last tip must be autoclaved between each patient. Tiger: Julie, I really appreciate you sending a text message, “Hey Tiger what did you do in section control with all the zen people?” This is a big subject, a lot of people talk about and you then came up with such a cool title Ten Things That Every Dental Assistant Should Know About in Infection Control. Tiger: I know that our assistants are busy but a lot of them will be able to watch this later. So let's just dive into this. Just I can't even add my two cents into this. This is a new subject for me I'm taking notes. Julie Varney: You can't? You don't know anything about section control Tiger: Literally I'm going to take notes. Julie Varney: You're going to take notes. All right. So first things first, we start with your PPE. [1] Everybody knows about the PPEs but what they sometimes fail to use are everything of them. Right, so sometimes they might not wear goggles, so we should always be wearing our masks, our gloves, our goggles or our face shield and we should always be wearing a gown with our arms covered. So we should not have our arms uncovered. Julie Varney: If you don't want to wear it to the office you could always take your lab coat on and off before you leave the laboratory. But those are the four things that protect us and protect the patient from us. So we definitely should be wearing those. There are other times we should wear them through processing instruments and breaking down and cleaning up a room. So those are our four main PPE items. Julie Varney: Our next thing is [2] utility gloves. So utility gloves are very underutilized in a practice which is according to OSHA is a no-no. We should be using them. So utility gloves should be worn when breaking down and cleaning up a room disinfecting it, when you're transporting your instruments from the operatory to the sterilization area and also they should be worn while you're processing your instruments in the sterilization area. Julie Varney: They need to be leak puncture proof and they need to cover your arms. They do have disposable ones by Halyard I think it is. But you should have a pair kind of everywhere. Where you're going to be using them. Julie Varney: So our next thing that people do not do that should be doing is when you transport your items and your instruments from the operatory to the sterilization area, they need to go in a [3] leak-proof, closed, puncture-proof container. So if you use a cassette system, the cassettes have holes in them so that doesn't classify as a puncture proof leak-proof container. Julie Varney: It has to have a lid or a locking lid. Because the need to transport them so that nothing happens. So if you bump into somebody they're not going to get poked or cut. So we need to make sure that when we transport, you have a bin that keeps those instruments safe from harming others and you're wearing your utility gloves. Tiger: You have to have utility gloves when you grab the tub with instruments to bring them into sterile. Julie Varney: Yeah. Absolutely, and this is the safest practice for the assistant or the hygienist or whoever's turning over the rooms. Because we don't want to risk any type of injury that's going to get them hurt on the job and that's more paperwork so let's just do things the right way the first way. Tiger: Wow. Okay. Julie Varney: Next is, [4] disinfectant. There are lots and lots of products out there which people don't realize is that there's a one-step or a two-step process. So you need to read the instructions for use on your containers. Because some of the disinfectants that we use to wipe down our rooms are technically a two-step process. But they're being used as a one step. Julie Varney: So a two-step means, if you're using a Cavi-wipe has to be used once to clean and then it has to be used again to disinfect. So if you're using a product that is a two-step you have to use it twice and you have to use more of it. Tiger: So, meaning we wipe up the surface first and then we take another one and we have to wipe up the surface again? Julie Varney: Yeah. Because with a two-step process, you have to pre-clean and disinfect. So if you read the back, whether it's Birex or Cavi wipes, any type of disinfectant that's EPA regulated so we can't use Lysol FYI. Lysol is not EPA regulated or hospital grade. They tell you the instructions for you. Whether you have to pre-clean and then disinfect or if there's one step. So often one by Scican is a one-step process so it saves you time and it saves you money because you're not using as much of the product and it's also healthier for you. Tiger: Do you know what other products are one step? That's probably something I should know. Julie Varney: Yeah, well I believe Cavi wipes has now a one-step process. There are a couple of other products that have converted over to being one step instead of pre-cleaning and disinfecting, they now do both. You just have to read the directions and their set time and all that stuff. Tiger: Like a one or three minutes? Julie Varney: Or on Birex is ten minutes. I think it's ten minutes. Birex. We shouldn't be spraying because then you breathe that all in and we need to make sure that when you're using these products you have all your PPEs on because it's very important that you don't breathe in all those aerosols or all those chemical smells. That's not good for your health either, so we want to make sure we have our PPEs on. Tiger: So you're saying if they're alcohol based don't be smelling? Julie Varney: Well, some of them are alcohol based but you need to make sure you have your mask on and your goggles on. Tiger: Well I've experienced that. In a couple of the offices. I went in and smelled all the alcohol base so we won't talk about it. Julie Varney: Lysol is not utilized. You cannot use Lysol it has to be EPA regulated at a high level. Tiger: What did step one or step two or it's just the nature of the product, one product would be two- step and one product would be one step? Julie Varney: It's just the nature I mean, it's just what the product is made. It's not they're better than any other product. You have to read it, the instructions for you if you're using Birex that's a two-step product you're going to want to make sure that you're doing those two steps so it's very ineffective. You might not be killing everything if you only do it once. When it's a [crosstalk 00:07:43] process. Tiger: Makes sense. Julie Varney: Check your labels, always read your labels on how to use things. Julie Varney: So next is ... I'm going to go over [5] loading the autoclave. This is a big topic. Like paper or plastic. Up or down. So one: always read your manufacturers whether you have a Statim or a Midmark or I think it's called a Tuttnauer the big huge gigantic one. Read how they tell you how to load the autoclave. That is important. Julie Varney: Midmark, I do know, are plastic up and I think the theory behind this, and this is just my theory is because when you put the plastic down and the instruments are maybe a little bit wet, the water's going to pool on the plastic the air can't flow and dry the plastic as much as when it's paper down. The paper gets wet but the air dries the paper. So and the instruments don't sit as much in the plastic so it's always plastic up, paper down for Midmark when loading. Tiger: Paper down. Plastic up. Got it. Julie Varney: I want to make sure that you're not over packing the autoclave because you have to have certain airflow to let everything, one: get sterilized and two: get dry. If everything is compressed it's not going to get the airflow that it needs. So you can either stack them or you can lay them all spread out but you need to make sure that they're not compressed and on top of each other. Tiger: That it? Julie Varney: Okay and that's when things melt. So a lot of people complain that “All my X-Ray rings melted.” Yeah, that's because you probably packed the autoclave and they had no room to breathe or let the heat escape so the heat got trapped and it caused the rings to melt. Tiger: Got it. Julie Varney: Also, on your pouches which people sometimes don't have a tendency to watch. There are indicators that are external and internal. The pouches must have an external and internal indicator so that you can tell that it was properly sterilized. Tiger: Or they have these little dots or something? Julie Varney: Yeah. In the corners, the ones you can kind of peel back and you can feel. But then there are also ones in the corners in the pouches that you can't touch that are in between the plastic. So there's usually, whatever brand you're using, most of them, I believe, I've never seen one without, have an internal and external. Tiger: Got it. Julie Varney: When you're using cassettes because they're wrapped in a blue paper with tape, you need to use an internal indicator strip and put it inside the cassette. Because the paper and the tape only have external. Tiger: Okay. Wow. This is a lot of information. Julie Varney: These are the most things I see are done wrong. Tiger: Okay. I'm ready for the next one. Julie Varney: The next one. We need to be weekly checking for [6] testing our autoclave for Spor Testing. It's not okay to not do this. Because Tiger: What is it called? Julie Varney: ... if it's killing everything it needs to kill and if it's properly functioning. Tiger: Spore checking? Julie Varney: Spore testing yup. Tiger: Spore testing. Julie Varney: Yeah you could automate that on your system. But it's very important that you do it if you have more than one autoclave or sterilizer, that you are numbering them because the next thing is all your items that come out of these sterilizers need to be dated. Cycle dated. If you have more than one autoclave, which autoclave they came out of. Julie Varney: Because, if something fails, we have to have a record of instruments that maybe were processed before or after. Because all of the instruments that come out need to be date stamped, cycle stamped and they're only good, they say the recommended, for six months. Julie Varney: So if they sit in the drawer for two years, it's highly unlikely they're still sterile. You might want to redo them. Tiger: Wow. Okay. Got it. Julie Varney: All right. My number nine was always read your instructions for you. Always on everything. If you don't know about the product. Read it. Tiger: Read instructions? Did you say number nine? Julie Varney: Number nine. Read your instructions. Tiger: Number seven? Julie Varney: Number seven? Number seven was the date of the item. Julie Varney: Wait, you missed it? Wait no, eight was, monitor your autoclave. Tiger: Yup. Julie Varney: Seven was, date your items. I mixed them up. I read it wrong. We'll recap them all at the end. Tiger: Yup. We will. We will. Okay. Julie Varney: And then. [9] Number ten is annual training. You should be getting training once a year in your OSHA and your infection control standards. Do the full office. Three, four hours going through all your processes, checking everything, your eyewash stations, your fire extinguishers, your emergency evacuation plans, your emergency plans. These things should be trained and checked once a year. Tiger: Okay. So, how do people go about them? So let you say I'm in the office, I know I haven't done these in a while, what do I do? Call somebody? Because I don't want to call somebody and somebody reports me that I haven't done that in a while, so what's the right way to do it? Julie Varney: Usually you only get reported if someone complains but there are tons of people to reach out to but you can do in office training that is three or four hours. Some people have CEs they can give. Sometimes, myself, I'm going to tomorrow. I have a four-hour infection control training and OSHA, it'll be fun. But it should be customized to your office. It also should provide CE because 90 percent of the licenses out there need CEs. I know if you're a lead assistant you need two CE a year infect control. Julie Varney: But also if you don't know there's https://www.osap.org/, you can reach out to for $150 dollars a year, you can get a membership to OSAP that has all this information about infection control on it. Right at your fingertips, download form, figure it out, they have it all right there for you. Julie Varney: They promote the safest dental visit. When you send the file off an email, I will give you a code Tiger so that they can get 50 percent off their yearly membership to this organization. Tiger: Fantastic. Julie Varney: I know. But there's no reason why any dental assistant out there should not know the proper way. Because there's so much information out there and so much free information out there that they should know the proper ways. Tiger: Right. So, do people really need to pay for OSHA inspections? Is it somebody that has to be certified who does the training or it can be anybody? Julie Varney: Well, there's credentialing. I mean people have credentials in this stuff. I don't think there's a certification in OSHA but there's a lot of experts out there and I would definitely do your research before you hire somebody to come in. Because if they tell you wrong and then you're doing it wrong, there's a lot of fines behind this stuff. Julie Varney: So really, if you hire somebody to come into the office, there's Dr. Kathleen Schrubbe, she's right there in Illinois. She does a lot of infection control in OSHA, and stuff like that. Linda Harvey, she does all the HIPAA, she's very good at that stuff so there's a lot of experts out there and you want to go with that just not winging it. Julie Varney: I know HIPAA but I'm not an expert in it, I could do a yearly training to update you on it but if you're just starting off the bat, I will funnel you to Linda because she's an expert in the HIPAA. Tiger: You got it. All right. So let's do a recap. Julie Varney: All right. So, number one was your PPEs. 10 Things Every Assistant Should know about Infection Control: PPEs - 4 items - mask; gloves; goggles; gown Utility Gloves Transport bins - to transport our items from the operatory to the sterilization area in a closed puncture proof, leak-proof container. With a biohazard sticker. Disinfectants - 2 step or 1 step. One step or two-step and are you doing, if you're using a two-step, are you doing the true two steps. Loading Autoclave - Paper down. Plastic up. Dating Indicators on pouches - Loading the autoclave indicators, on pouches, there's external and internal. Then on the wrap, they're on paper and tape, the tape changes to stripe but we also need to put an indicator inside our cassettes. Seven, was the date your items by load date and autoclave if you have more than one. Eight was you need to weekly spore test your autoclave or whatever sterilizer you use. Then always read your IFUs, your infection, we're talking about infection control, your instructions for use on any type of product. Always read. Read. Read. Read. Ten was your annual training. Because things change, just like one of the changes last year was all handpieces that are air driven must be autoclaved, the last tip must be autoclaved between each patient. Julie Varney: Once a week yeah. Then always read your IFUs, your infection, we're talking about infection control, your instructions for use on any type of product. Always read. Read. Read. Read. Okay. Then ten was your annual training. Because things change, just like one of the changes last year was all handpieces that are air driven must be autoclaved, the last tip must be autoclaved between each patient. So your hygiene close feeds that people technically did not do that, they would wipe them down with a Cavi wipe or some type of disinfectant. They now have to be removed and autoclaved between each patient. Just like your high speeds. Tiger: So what's the instrument? Julie Varney: Your air driven motors. Your high-speed handpieces, your low-speed handpieces. The high speed always had to be autoclaved but the low speed now also is regulated to be autoclaved between each patient. Tiger: We'll put that as the bonus section. Julie Varney: Yeah. Put that in the bonus section. But if any assistant has any questions you can feel free to reach out to me. Like I said, join OSAP there's a ton of resources out there. There are checklists, there's protocol on that website. For $150 bucks a year, your whole office can know how to do everything. Tiger: Right. As a closing note, I'm still trying to wrap my head around how much dental assistants should know. Julie Varney: They should know as much as they could possibly know right? Tiger: Right? Just between this stuff here that we covered. My notes here, you can see how many notes I took. Julie Varney: You took a lot of notes. Tiger: And order supplies, and turn over the rooms, and assist the doctors Julie Varney: On fire that little Tiger: And then we probably didn't even scratch the surface of really going into the OSHA and all that stuff. Julie Varney: No, these are just ten common things that I see that are done wrong or done maybe half -done at times. That shouldn't be. It's really important that we stick to a good solid infection control plan because it only protects not ourselves, but our patients and we don't want to be on the news for improper stuff and we don't want to be closed down or end up in jail. Or hurt someone. That's the biggest thing. Who wants to hurt somebody and they end up with some infectious disease. Tiger: Exactly. Awesome these are really cool. Ten actionable steps that any office can use. I love that, it's tightly packed and that in the notes I'll make a note on how people can reach out to you. Julie Varney: Yeah. Absolutely. Like I said we'll send them a code to get the credit for CEzoom for watching the webinar. I'll send you a code for the OSAP for them to get 50 percent off of the membership if anyone wants to sign up. Tiger: That's awesome. Julie Varney: Get all the resources and we hope to see you at that, the annual conference which we will be talking about infection control on there. So they'll learn more about that and the whole process. Julie Varney: Like I said it's just scraping the surface but if you don't know when you need to ask and if the older generation of assistants hasn't had any training we need to get some training too because we teach the younger generation the wrong way and it's not okay. CODE: darocks50 to use with OSPA.org

Dear ZenFamily, Thank you to each and every one of you for participating in our live events and webinars this past week! We’ve gotten so many great questions in regards to our webinar on Monday 4/20 with Tim Twigg and on Wednesday 4/22 with Mary Govoni. Both of these webinars are eligible for 1 CE credit hour each! To find more information on how to obtain your CE certificate, please check the notes section under these two webinars in your Zen account. So here is a recap of what we talked about: Monday, April 20: Although Mr. Tim Twigg has joined us for a live webinar at the end of March, we invited him again to give us updates and share some news on what’s been happening with the HR aspect of dentistry. He answered all the great questions that were asked during the webinar such as how the changes have impacted dental practices, staffing levels information, PPP Loan Opportunities, the hiring process for dentists and much more. Here is where you can find the full webinar: https://youtu.be/favEZeyhIsY https://open.spotify.com/episode/1Qs2RAST0FeHaVOq2QQRoa Wednesday, April 22: By many of your requests we invited Mary Govoni to the live webinar to discuss one thing that ALL offices are worried about - how we are going to protect our patients, our staff and ourselves. In addition, Tiger went over how to plan to purchase the most essential items before reopening the practice. We want to make sure we all come back STRONG and prepared when the big day comes! Please find the full webinar here: https://www.youtube.com/watch?v=Quur8sGY7sY&t=1404s https://open.spotify.com/episode/6g0KmLgVqyRqXpZKIeThMQ During each webinar, we covered numerous topics on surviving through COVID-19 and staying strong during the times of the unknown! There were quite a few interesting resources, links, checklists and recommendations made during each webinar so I’d like to share them with everyone here: 4/20 Live: The HR Conversation with Tim Twigg: -Here is the link to the "Alternative Work Schedule" for the dentist in California: bentericksen.com/alternate-workweek-schedule/ -Here is the Coronavirus specific information link on Tim's company website: bentericksen.com/coronavirus-faqs/ -Aspirations from Tim’s Wall: https://drive.google.com/open?id=1YuspbC4EFcpXj9Zih4Xm1LFM2GQ823x3 4/22 Live: Guidelines on how we are going to protect our patients, our staff and ourselves. Understanding the purchasing constraints of PPE -ADA COVID-19 Resources: success.ada.org/en/practice-management/patients/infectious-diseases-2019-novel-coronavirus?utm_source=adaorg&utm_medium=globalheader&utm_content=coronavirus&utm_campaign=covid-19&_ga=2.215779103.94097617.1587701693-788863450.1587586893 -COVID-19 Questionnaire: drive.google.com/open?id=1Fyk-lJXvHCgrsBmnsaub4O0PAlwSDh1X -OSHA Compliance Checklist: drive.google.com/open?id=0B30ztLGC7S9hOGp0QTR4VHF1VVdfNHcyMmU4RzViLUFHdTM0 -Oral Biofilter (OBF) is a new product and it is awaiting FDA approval: www.astradentium.com/ -Information on the ADS Dental Systems: www.youtube.com/embed/6HN1SOYQnts -Prior to reopening the office, please treat the water lines. Here is an excellent resource: proedgedental.com/ And here are the details for the upcoming events for the week of April 27th: 4/27 Live 2 pm CST: Dr. Brett Gilbert on Positive Mindset and Why Change is Crucial for Self Development (1 HR CE) https://app.livewebinar.com/561-547-984 4/29 Live 11:30 am CST: Don't be Moody on Wednesday with Dr. Justin Moody https://app.livewebinar.com/121-694-682 5/1 Live 2 pm CST: Dental Assistants Share Their Side Hustles https://app.livewebinar.com/982-547-546 We hope everyone is enjoying the live events! Stronger together!

Dear ZenFamily, Happy Monday to all! I hope everyone had a great weekend and ready to start this week with full energy and potential! Last week here at Zen we had two live webinars with four phenomenal guests! On Monday, 5/4, Tiger was joined by Dr. Justin Moody, the owner of West Horizon Dental Group and the founder of the Implant Pathway. To find out more about Dr. Justin Moody please see here: https://www.implantpathway.com/justinmoodydds/. Tiger and Dr. Moody discussed what the first day back to the office was like for Dr. Moody, how his team was doing during the time of quarantine and now back to work, what it means to be a CEO and a dentist, and much more! And on Wednesday, 5/6, we invited Mary Govoni along with Mike Rust and Kellie Thimmes from ProEdge Dental Water Labs in CO. This webinar was eligible for 1 CE credit hour. To find more information on how to obtain your CE certificate, please check the notes section under the 5/6 webinar in your Zen account. So to summarize, here is a short recap of what was discussed as well as links where you can find the full webinars and listen to the podcasts: Monday, May 4: We  brought back Dr. Justin Moody to talk about an emotional roller coaster we are all going through and how to best prepare for getting ready to reopen. We discussed what steps Dr. Moody and his team took to get through this across all of his businesses. Tiger and Dr. Moody covered leadership, how to manage change, and communication skills with the team. Here is where you can find the full webinar: https://www.youtube.com/watch?v=-bQxeK1Zzko&feature=youtu.be https://open.spotify.com/episode/5wh3OqRq53TU2CqxTKrXd5 Wednesday, May 6: Will your dental unit water be safe when you reopen? By many of your requests we invited Mary Govoni, Mike Rust (ProEdge Dental Lab) and Kelley (ProEdge Dental Lab)to the live webinar and we discussed if your waterlines are ready for the big reopening. Since your dental units have been sitting idle, water can become contaminated, and before opening the practice back you need to make sure to follow protocols. We discussed what it means to test the water lines and how soon this should be done, the GOLD dental water formula of SHOCK->TEST->TREAT, we also covered the difference between in office tests and the lab tests and answered commonly asked questions when it comes to water line safety within your practice. If you've always wondered what the difference is between purging and shocking water line, please watch the full webinar here: https://youtu.be/5twyx4pMiJU https://open.spotify.com/episode/1LgCsfJCvJ7fEkr9yCbLoL During each webinar, we covered and referenced lots of resources in regards to COVID-19 and water line treatment prior to reopening. Please find this information here: ProEdge Dental Water Labs: https://proedgedental.com/ Information from OSAP.ORG on Dental Unit Water Lines https://www.osap.org/page/Issues_DUWL_7XXXX/Dental-Unit-Waterlines.htm The GOLD and simple water line formula for every dental office is: SHOCK->TEST->TREAT Waterline Testing Log: https://drive.google.com/open?id=13pDuCMjrcxbDClBm2l1jluQn4YnjLhhE Here are the details on the webinar coming up for the week of 5/11: By many requests, we have invited Mary Govoni to a compliance series webinar on "How to Control Aerosol" for the week of May 11! The time and date is TBD at the moment but coming soon. Stay tuned on your ZenAccount, Instagram and Facebook! We hope everyone is enjoying the live events! Stronger together!

Today, it’s the beginning of our sixth weeks of quarantine: time to make a point. On the last Tuesday, our President, M. Macron announced the extension of the shelter in place order for 30 days.  The end of the quarantine will be May 11th. If statistics look good, schools and businesses will open on this date, but step by step. For the health industry, each profession will organize itself in order to limit the spread of infection. In France, each dentist belongs to an organization called “Ordre des dentistes” It’s a national Order that has local chapters.   This organizations allows the opening of the dental offices (for emergencies and other treatments) but we don’t currently have enough PPE to work in good hygienic conditions. Today, dentists work 1 or 2 days a week, just for seeing emergencies and their local Chapter supplies PPE accordingly .On the Tuesday, Dentist have received PPE used by veterinary. The goal is to work until the May 11th.  We don’t know when the peak of the epidemic will come, but we can already plan for a long period with covid (we think until at least August). So, at this time, nobody has received official instructions from the government. People are creating their own re-opening strategies : how do you organize our dental : masks, PPE ? What type of mask protect ourselves for the virus? where can we buy the PPE ?. Some masks are selling on Alibaba, Shein.. and who are going to pay for these new materials. For information, a PPE=9 $. Today, I have received an email from unions with huge informations :  40 000 French dentists use 4 millions masks (FFP2) and 80 millions growns ( 1 month). At this moment, our supplies are unable to deliver this quantity of material ; the delivery time is june. Conclusion : Government propose dentists to open increasingly their dental offices in order to share the last stocks. In addition, some laboratories are implementing screening tests (for testing patients and teams). The goal would be to test patients before the treatment. Another test is in progress for immunity immunity. About the near future : we are going to go from red to green (Tiger’s question). So, we live in a country with national coverage for dental and medical expenses. Even if we have a lot of unemployment in the future, people will continue to visit the dentist because their fees are reimbursed by national health care and insurance. The biggest issue in France is not losing money (cost for PPE, less patients in a day for safe conditions) but the amount of patients to serve AFTER the quarantine. The phone number is opened in order to answer to patients and we already know that the re opening is urgent. This crisis, unpublished,  allows to create new connections and new procedures.  I think this is a good opportunity for us to look at and reflect on our current system. How can we make it better in general? How can dentists better protect themselves in their everyday work? What will the patients be expecting now when they visit the office after Covid? And how can we provide that care they are expecting?  So it’s a good time of reflection. #strongertogether. Emilie

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!