The Art of Clinical Research and Experimentation in Dentistry





By Lexi Marino August 14, 2020

Rolando Mia, from Zyris, hosts a video series focused on the latest news, topics, and conversations happening in dentistry featuring dentists across the nation. In Season 2, we’re focusing on, “What’s Working and What’s Not”, where we’ll debunk myths by assessing trial and error since the start of Covid-19 in dentistry. 

In this episode, we interviewed Dr. David A. Rice, owner of the practice David Rice, DDS – For Confident Smiles. The purpose of this discussion was to understand what has worked, since re-opening during the Covid-19 pandemic and get his insight on experimenting with new products since the start of Covid-19 to reduce dental aerosols.

Watch this video to learn the following:

  • Researching specific products for aerosol reduction – what works, what doesn’t
  • Introducing new products to your team for their safety
  • Having mentors and connections with people you trust to give good advice
  • Importance of intraoral suction vs. extraoral and capturing aerosols at the source

Transcription: 

Rolando Mia:

Good afternoon, everybody. Welcome to Dental Voice. My name is Rolando Mia, and we’re here with Dr. David A. Rice.

So, the purpose of Dental Voice is to hear directly from clinicians and understand the experiences that they’re having, get their perspective on what’s going on currently and get some advice from them. What we’re talking about in our second season is how to separate reality from speculation or just total fiction. Today we have Dr. David Rice who is a general dentist who has practiced for over 30 years. He is an instructor, a product advisor to the Kois Institute, and he’s also part of the AARD.

So, what I’d like to understand is, give a little background into the experience that you’re currently dealing with relating to COVID-19 now that we’re back and working again. What’s that like for you and how is that going?

Experiencing COVID-19

Dr. David A. Rice:

We’ll it’s been a journey from shutting down the office to doing nothing and then trying to figure out what we wanted to do, I was frozen for a while. I didn’t know what to do. I really have to hand it to John Kois because he helped me and he said, “Dave, we need to figure this out, help me form a task team.”

There was a three-hour webinar we participated in. If you go on their website, you can actually view a lot of the recommendations or a whole series of PDFs that you can send out to your patients. So, there were so many smart people in that taskforce assessing what to do to make the office safe because we got so much bad press.

What I mean by that is the press saying that we were in the 95th percentile and our hygienists were 99th percentile. It freaked out my staff when I had my first staff meeting, it was incredibly disheartening for me because it’s a profession I love, and I love doing what I do. It seemed like people were really scared because they didn’t know. So, your point is a good one – there’s so much out there. How do you separate the wheat from the chaff? That’s always been the issue, but I think the issue is stronger now because the stakes are higher. We’re dealing with a lot more money and I think we’re dealing with life and death at a certain point.

Rolando Mia:

Right. So, it’s amazing. I appreciate the candor. You mentioned you were kind of frozen and terrified. How did you get “unfrozen”? Now that you’re back at work and you’re treating patients. What was that process like?

Dr. David A. Rice:

When John approached me and said, “We’re getting together a task force.” And he asked me if I’d like to be on it. I jumped at the chance to do it. There’s a chat line that I’m a part of where there are so many people asking so many questions. So I started compile in a PowerPoint, everything that seemed to be applicable, whether it was air handling, UV lights or antibody testing, etc. And then I spent the day just researching it, trying to say, “Okay, what are we going to do about that? What are we going to do about this?” Also, the task force had so many brilliant people on it. People that had knowledge in certain areas, I have no knowledge in. So, I took the area that I like, and that was the “Dental Product” part.

However, there were so many other gifted people that collaborated – it was actually a fun project because we were able to meet like once a week and just discuss what was going on. It helped to ground me.

Aerosols, Infection Control, and Product Research

Rolando Mia:

Oh, that’s so cool. Thank you for sharing that. It’s interesting. The biggest topic that has come up was this whole issue of aerosols and infection control. What did you discover with regard to that and what are your thoughts now that you’re back and working again?

Dr. David A. Rice:

Right. That’s so fascinating to me because I think it’s really two levels. Everyone talks about the aerosols, but I think it goes beyond that. I think it goes beyond like these people that are emitting the disease. I mean, there are people that are called, “Super Emitters”. We don’t know because they’re breathing through their mouths, or through their nose or what, but there are certain people that actually produce more of the disease than others. If you have somebody coming in that’s actually has the disease and they don’t have a mask on, it puts you and your staff at risk. So yeah, to your point, the aerosols, I think can be trapped fairly easily if you properly maintain your HVE. However, then you need to look at, how you evaluate it.

Well, take a 2L jug of water, open up all the ports in the room and then suck it up and see if it can eliminate that 2L in 8 seconds. If it doesn’t, you should look at cleaning out your canisters, doing some things to help bring that closer to 8 seconds. If you can’t achieve that, you may have to think about retooling the office.  With people on slabs and people that don’t have room in their mechanical rooms, I mean, that’s a big deal. It’s almost like telling people they need a room that has like a negative pressure room. It’s like to create that in dentistry, after we’ve had these open designs and things like that, it’s a nightmare. So, with the aerosols, you have to figure out where you are going to attack it.

Are you going to attack it right at the source or going attack it slightly away from the source? Are you going to let it get into the air and then try to attack it? So, each one has its own thing – my favorite is to work with a vacuum pump. The reason I like the vacuum pumps is because all the air that’s exhausted from that is going to the roof. It’s going outside. You do not have to condition it. With these super vacuum cleaners that hang outside the mouth, all of a sudden, you’d have to either deal with HEPA filtration or you have to do UV and help find some way to condition it.

Then the question is, did you catch it? Did you catch the virus? Now you’re taking the virus and expelling it, which again, there hasn’t been a lot of science on it, but you have to look at what they do know, and they think that they have it.

So, how do you create a negative pressure room without building one? Those HVE’s that go into the mouth, like the Isolite can constantly help pull the aerosols. Even when patient breathing, it helps get rid of the viruses. I’m not here to talk about Isolite, but it’s a great tool. You have to think about something like that in order to do this.

I have an assistant working with hygiene. So, they’re running the HVE every time they do the EMS, which is a glycine unit that polishes teeth, or when using the ultrasonic. So, now we have a hygiene assistant- we’ve changed that in a way to try to help decrease aerosols. I’m trying to get them to incorporate the Isolite in combination with two HVE’s. The problem is that some patients, it creates so much coolness that it’s sensitive for them. So again, this is a learning curve. I don’t have the answers, but I know that we’re trying different things.

Rolando Mia:

So, it sounds like in the absence of definitive information or in the absence of direct guidance, you are actively experimenting with different things. I love the fact that you are so research based – you’re collecting the information and then doing what makes sense. Did I understand this correctly?

Dr. David A. Rice:

You’re exactly right. I try to be research based. The problem is sometimes the research lags. I mean, we’re ahead of the research now, by the time the research catches up to us, you have to kind of say what makes sense. So, if anything, you really have to start to learn how to think, think creatively, think deductively, think intuitively and try to come up with solutions. Just make sense. I mean, if you put an HVE that’s suctioning out 9mm of mercury and moving at a rate of 25 miles an hour, and you put that next to the tooth (two of them, one on each side) you do not see spray on glasses like we saw before this whole COVID thing.

I didn’t even think about the problem before. We used to give a patient a towel at the end to wipe their face. Now we don’t even have to give them a towel because there isn’t excess spray. Very little.

Communicating with Dental Teams About COVID-19

Rolando Mia:

Yeah, that is awesome. You mentioned that your team was definitely feeling apprehensive prior to coming back to work? What was the message that you shared with them with regard to that? How did you overcome that with them and reassure them?

Dr. David A. Rice:

I just told them that I’d been working nonstop, trying to figure out how to make it safe for them. So, I made a commitment that I wanted to make it safe. Providing N95 masks that they can wear all day or creating things like PCO units, photocatalytic, oxidation units that go into the central system and then individual units. We bought an all new dry vac HVVE system and replumbed all that for the office. Even with that, one of my hygienists whose daughter is medically compromised, quit. She goes, “I cannot imagine if I bring this home, she goes, that could be the end.” She’s been with me for over 20 years.

It was hard, but I totally understand it. When I first talked to her about COVID-19, she was one of the first to say, “Oh, it’s not a big deal.” However, as she started to read stuff, it became more and more difficult for her. So, my heart went out to her cause, cause your staff becomes like family. So, you have to say to yourself, “Nothing about my dental practice is as important as your family. You need to go home and take care of them.”

Rolando Mia:

Wow. Did you experience a similar perspective from your patients as your they started coming back into the office? What was that experience like?

Dr. David A. Rice:

Once in a while, you get somebody because, we take their temperature and they hem and haw about that. They can’t come into our waiting room, rather, they sit outside and now they’re hot. We take their temperature to have a second type of well challenged thermometer that goes sublingual. So, then we can take a second type of temperature to make sure it’s accurate because you lose one patient for a two-hour appointment because they have a high temperature.

So, you need to have different ways to take the temperature, bring them back, and you make them wash their hands – that was probably one of the biggest things. A couple of patients kind of balked at that. If you want to be a patient here, you have to do what we’re saying. That’s the other thing, we learned how to make hydrochloric acid, you fog it and you can spray it. And so, I thoroughly think chlorine is one of the best disinfectants.

There’s a been a lot of good that’s come out because of this. I think we’ve really upped our level of trying to be more like a surgical suite. Our infection control has really upped its game which is nice to see because it helps in a lot of different areas, not only with COVID-19, but with hepatitis, tuberculosis, or with anything.

Rolando Mia:

It makes everybody at everything safer. So, have you run into any patients who just don’t want to follow the protocol?

Dr. David A. Rice:

No, I’ve seen some videos of patients that have been pretty opposed, but that’s not my patients. That’s my patient based they are pretty compliant. They’re appreciative that we’re back into work and they understand that we’re wearing the mask to protect them. As soon as they take their mask off all bets are off. They could just infect us like crazy. So, they appreciate us putting ourselves in harm’s way.

Rolando Mia:

It’s great that you’re not running into problems. I’ve also seen some of those videos of some people who are just really demanding – it’s being done for their benefit and for their safety. It’s interesting, we spoke a little bit briefly around this whole idea that you do get to choose who you bring into your practice.

Dr. David A. Rice:

You do. Absolutely – it’s your choice. You just have to create a space for emergent care and give them three referrals and they’re on their way within a month. Tell them, “You have a month to find somebody else. It’s been a pleasure knowing you, I’m sorry, it didn’t work out for you. If you come in with a problem, I’m here for you.” Emergencies are very rare. I mean, true emergencies. We found that when we had to shut down and they gave us the definition where the true emergency was. We can hardly see anybody if we follow those guidelines.

Clinical Research and Making Investments

Rolando Mia:

From a practice perspective, one of the things that a lot of the clinicians are talking about is the level of investment that’s now needed in order to meet safety protocols. What’s your experience with that? And how is that going with you?

Dr. David A. Rice:

When this pandemic first hit my wife, she knew, she knows me. She came in the office because I was looking at a bunch of stuff and she goes, “I don’t want you to buy anything for a month.” She knew I would buy everything, and not only do I buy everything – I buy two or three of everything to try out in different ways. So, you have to put some money out there and try to see what works for you, because what would work for me is not necessarily going to work for somebody else.

So, you can provide certain things but even for my hygienists, I provide for them the Isolites and I said, “Listen, we have to make this a protocol and you have to at least give these a try.” They’re not used to doing it, however, if you’re not used to something, you’re going to fight it. Number one, it wasn’t their idea, so it was coming from me. It’s not like my hygienist came to me and said, “Hey, provide these for me.” So, it was upside down that way, which is a shame. I mean, she came to me with different things that she wanted me to buy and I’m like, “No, that does not make sense to me.”

Rolando Mia:

It looks like you have to make that investment, but right now it sounds like that you’re discovering what is working and what is not, is that correct?

Dr. David A. Rice:

Correct. Yes. Even with fogging with, I mean, what does 20-micron particle size look like? How do you adjust your fogger to create that? And then, how much time do you put into it and how much solution do you need to do? Everything is a learning curve. It’s kind of a fun time in a way to try to discover this, but it can be frustrating because the one question I don’t have an answer to yet is who’s going to pay for this? Right now, I’m paying for everything, right? I want it to be safe, but at some point, it’ll be interesting to see how it shakes out.

I mean, ADA, has had talks that they’re going to have a special code for COVID-19, they can put some kind of fee in for that for free. Right now, there’s nothing that exists like that. So, you’re just doing it because, you know, it’s the right thing to do.

Experimenting With New Products for Aerosol Reduction

Rolando Mia:

You are doing things because you feel it’s the right thing to do. That’s very reassuring for me as a patient. I think that’s important. I especially like the context that, because you don’t know, you experiment, you use things, you can’t figure things out without actually doing them.

Dr. David A. Rice:

I’m a kinesthetic person. I mean, I was constantly breaking my dad’s stuff when I was a kid because I was trying to figure out how it worked. I broke so many things.

Rolando Mia:

Now it’s made you who you are, and it’s why you you’ve been in practice over 30 years. It sounds like things were going well for you. I’m very happy about that. So, I’m curious, because you’ve mentioned it a couple of times you use the Isolite or you hadn’t before, is that right?

Dr. David A. Rice:

I hadn’t really used it before, but one of my friends, who is one of the best dentists in the country is a friend of Dr. Hirsch, John Derango and Derango swears by it. He’s never led me wrong. He uses it all the time because he doesn’t have an assistant always. So, he just thinks the world of it.

When this whole thing came out, he says, “Dave, you have to do it.” And even my friend Scott, he teaches out at UNC, they haven’t down there in North Carolina with all their students. Scott is also a person I go to when I have questions about products. They’re two of the first people that I go to and they both are advocates of it. However, I don’t have a lot of personal experience with it or a lot though.

Rolando Mia:

No, but you made a decision and I appreciate that. What other products have you made a decision like that on just out of curiosity?

Dr. David A. Rice:

We bought a new HVE system. I’m a one doctor practice and it’s supposed to be an eight-doctor pump. It’s supposed to pull a lot of volume. Also, hypochlorous acid is really another big thing. We have hydroxyl units that have gone into the HVAC system and also standalone units. So, you can decide, you know, if you want ultra-voilet, upper UV light to disinfect. I didn’t go that way, but if something gets outside the mouth, now you have to somehow condition the air around you and, you know, are you going to use HEPA filtration or are you going to use a UV filter, UV light? Are you going to use plasma? Those are the three big players and some of them combined UV plus HEPA.

So, you have to decide, you know, are you going to go with something like a surgically clean air? How far do you want to take it? And again, my emphasis has been on trying to capture it at the site. I’m spending all my money to try to get two HVE’s to the site so that I have maximum velocity and maximum pull at the aerosol site. What I said makes sense is the Isolite, it’s continuous and it’s creating a negative pressure unit basically right inside the mouth.

So that that takes care of the first thing we talked about which is the aerosol. I think I’ve got that under control, but I don’t have the part under control where the people are. Meaning, they’re sitting there waiting for a hygiene exam, because really, they should probably be wearing their masks, or they should have the Isolite in. As, soon as they shut their mouth and are ready to do something else, they should put a mask on. I know that might be an extreme, but this is all new. So, we don’t know how much much is too much and how much is not enough.

Advice to Clinicians Who Are Struggling

Rolando Mia:

What advice would you give based on the experience that you’ve had based on the, the findings and the taskforce you have what advice for clinicians who are frozen and don’t know what to do next. What advice would you give them with regard to, how to move forward?

Dr. David A. Rice:

Yeah, that’s a good question. Find a great mentor. If I had a group of mentors, it’s Dr. John Kois, Gordon Christensen, I mean, he’s a great mentor and he and Rella produce a lot of good materials, the Dental Advisor. These are people who spend their life trying to figure out what works and what doesn’t work and who’ve been out there in the trenches. I mean, John Molinari with Dental Advisors. I mean, all those people. So, when they were speaking, I was listening to them and then I had to find out for myself, what made sense in my office and what didn’t.

My advice would be never stop being curious, just try things, get good mentors, because if several of your mentor’s kind of point to the same thing, maybe it’s something you should consider doing. Mentorship to me is huge because like John Kois says, “None of us are smarter than all of us.” Right? It’s that old Japanese saying.

Rolando Mia:

That is awesome. Thank you for that. First of all, really appreciate you taking the time and sharing your perspective and being so candid about the things that you’ve done. What final words would you like to kind of give out to our audience, those listening, patients or colleagues, or your team? What would you like to tell them as we finish this up?

Never Stop Solving Problems

Dr. David A. Rice:

Well, what you told me when the first time you caught me on the phone, you said, “what do you do every day?” I said, “I’m curious”, you said, “No, you do something every day.” Do you remember what you told me?

Rolando Mia:

What do you do every day? You solve problems.

Dr. David A. Rice:

Right? So, never stop solving problems. So that would be my advice. Never stop solving problems and never concentrate on the things you don’t know, because that stops you. That’s the thing that stops me so many times. It’s so it’s good to have somebody who can call you out on things. I think that’s the problem with the world is we build ourselves some kind of Gucci fortress where people can’t give us advice, or they might lose their head because they said the wrong thing to us. So always be open to advice.

Rolando Mia:

Well, first of all, Dr. David Rice, thank you for taking the time with us. I love the sentiment around experiment and then do what makes sense to you. Thank you for doing that. Have a great evening, really appreciate you joining us.

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