Dental Industry’s New Wave: Aerosol Reduction





By Lexi Marino June 17, 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 this episode, we caught up with Dr. Ann Marie Silvestri, the former Dental Manager for the County Hospital of San Mateo and adjunct professor at UCF and UOP. Dr. Ann Marie shares her experience of being a dentist for 40+ years and lends a reassuring perspective on how the dental industry has changed over the years.

Watch this video to learn the following:

  • What it’s like working in a clinic during the Covid-19 pandemic
  • The importance of reducing of aerosols in dentistry through continuous high-volume evacuation
  • Infection control in dentistry and how we’ve been doing it right for several years

Transcription

Rolando Mia:

Good morning, everybody. Welcome to Dental Voice. My name is Rolando Mia and I work with Zyris. Today we have a special guest, somebody who knows a lot about dentistry, who has an immense amount of experience and I’m really excited to hear her insights into what’s going on with regard to the COVID-19 crisis as well as advice for us. I’d like to introduce you to Dr. Anne Marie; she was the former Dental Manager for the County Hospital of San Mateo. She’s also an adjunct professor at UCF and UOP, had her own practice, and has been practicing dentistry for 40 plus years. I’m really excited. Thank you for joining us. Dr. Ann Marie, how are you doing?

Dr. Ann Marie Silvestri:

Thank you, Rolando. I’m doing fine. Entered a new stage of retirement and COVID-19 virus time.

Rolando Mia:

I believe COVID-19 was waiting for you to retire because it was fearful to come in before you retired. Is that, is that a true?

Dr. Ann Marie Silvestri:

Oh, that would be interesting if that were the case. I should have stayed there longer and gotten it out of there.

The Dental Industry and Covid-19

Rolando Mia:

You’ve been in dentistry and you’ve experienced over the last 40 plus years or so, probably so many different events that have affected the industry. When you look at the COVID-19 pandemic and the crisis, this is the first time I believe that it has been absolutely far reaching. What are your thoughts on that and what insights do you have about dealing with this right now?

Dr. Ann Marie Silvestri:

I’ve been doing this for quite some time. When I first started to practice in 1975, dentists did not use masks or gloves or anything and then the AIDS epidemic hit, and it changed the way we did infection control. I think this will be another change, an upscaling of how we do infection control. When I hear of what they’re asking the medical professionals to do, it’s what we’ve been doing in dentistry for lots of years. Your dentist wears gloves, your dentist wears eye protection, your dentist wears a mask and now they’re upscaling it to wearing a shield in addition. At the medical center we’ve actually been wearing shields for several years. So, when I heard of what they were asking for infection control, I literally said go watch what we do in dental.

Rolando Mia:

So, if you look at it, it’s not anything truly new in dental, it’s a protocol that’s already been in place. Is that correct?

Dr. Ann Marie Silvestri:

Very, very much so. I think that the idea of wearing the shield is new to lots of dental offices but we’ve done it for years.

Rolando Mia:

Wow. So, over the many years that you’ve been working, you’ve seen a lot of things come and go. From your perspective, what would you say is key advice that you want to give people to think about this issue and then overcome or navigate through it?

Dr. Ann Marie Silvestri:

Two ways for providers, I would say to be careful with yourself and your staff and your patients. For patients, I would say look at your dentist. I’m sure that he or she is wearing a mask and that’s to protect both of you. Eye protection really protects the dentist from splatter that can go into his or her eyes. Shields go over the eye protection as more of a protection. You know, I was talking to someone, they said they remembered going to their dentist and they saw splatter going all over with the dentist face in the old days. Yuck. So, give us a shield, you know, protect yourself. Both need to protect themselves. I would personally think that any patient that goes into a dental office with the “universal precautions” is as we call them, would be safe.

Dentists Finding The Right Information

Rolando Mia:

Wow. Thank you for that. I love the reminder that one, this has been in place for a while and then two it’s protection for both sides. We’re hearing so many comments and we’re hearing this anxiety around the uncertainty of what’s going on. There seems to be so much information we haven’t received clear guidance from the CDC, from the ADA, from the state organizations. How should people, from your perspective, digest this information? What information should you being listening to?

Dr. Ann Marie Silvestri:

All of it. I would say because we really don’t know, if you look back to the early 80’s when the AIDS epidemic was here, nobody knew what they were doing. Right? We started to take precautions because that’s what that we had to do. So again, this is another step up, but we need to learn from that experience that it can be overcome. When you go to a dentist today, they don’t care whether you are HIV positive or not. Everyone’s treated with what we call, “universal precautions”. I see this as a future as we go forward.

Rolando Mia:

Wow. Okay. You are so calm. There’s a confidence that makes me feel like, “Holy cow. Well this is going to be okay.” I love it. I appreciate you bringing that because there’s a lot of stress. People are having so much anxiety about the uncertainty of what’s going on. How are you so calm?

Dr. Ann Marie Silvestri:

Well, the thing is that in the early 80’s, when I was in San Francisco and there was a huge AIDS epidemic, one of my biggest refers was one of the doctors that was in the frontline of discovering AIDS and Kaposi Sarcoma. So along with him, I had to be comfortable in treating patients that were “infected”. So, we had to find a way, to protect ourselves and we had to protect other patients from getting this. I think that if you’re too fearful, you’re not going to be observant of what you need to do.

I personally think that anyone who goes to a dentist, who has been following universal precautions, will be okay. Today we’re only treating emergent cases. We’re treating cases that have less splatter value because that’s where we’re finding a transmission through the droplets. It said that this virus can stay alive on countertops for long period of time.

But see in dental we’ve always used the proper infection control mechanisms and wipes to clear off the counters, to clean the chair, to wait in between, to run the hand pieces to make sure they’re clear. We’ve done that. This is what we’ve been doing. I don’t think there’s going to be a big step up in what we do in infection control in dental. If you’ve been following universal precautions, the mask, the not the mask, I’m sorry, the shield might be new to a lot of offices. You go in kind of looking like you’re ready to step off on the moon. Right?

The Importance of Aerosol Reduction

Rolando Mia:

Awesome. Thank you for that. The one thing that that seems to be coming up, and this is prevalent, and I’d love to get your perspective on it. Up until this point, there’s been a protocol around infection control. However, what we’re hearing from other clinicians, from people in industry, is that the issue of aerosols has been something that people are aware of or people are knowledgeable about, but it’s not as prevalent as the spatter. The splatter spray – you can see that. But then what we’re seeing with aerosols is they are in the up to 10-micron range and can actually float around.

They actually emanate from the patient and go into what I’m going to call the, “clinician zone”, because as people are breathing, this is coming out. How do you see the heightened awareness around aerosols and the effect that they can have because they can carry these, these viruses?  The dental community generates amazing amounts of aerosols.

Dr. Ann Marie Silvestri:

So, I just want you to think back to a time that you may have gone to the dentist to get your teeth cleaned. Think back to that time and think about what your face looked like when it was done. It was wet; there was splatter all over ya. So that is in the air and that’s what we’re concerned with. One of the best ways to get rid of that is with high speed evacuation. You have a dental assistant sitting there with a high-speed evacuator. When that is turned off, where’s it going to go? A hygienist doesn’t usually have an assistant and the spatter is greater at that time.

So, several years ago, 2-3 years ago, we were introduced to the Isolite and it is continuous high-speed evacuation. I’m not going to advertise for you Rolando, but it’s made a difference in our clinics. I have to really say are our staff could work alone because everything’s being evacuated. We’ve done it for a couple years, so that’s not a concern anymore for us. The splatter is picked up constantly as long as that unit is on. So, I think the key is high speed evacuation, but how can that be done constantly? Have a dental assistant there or have a tool that does it for you.

Infection Control

Rolando Mia:

Awesome. Thank you for that. I appreciate it. The biggest fear that people are having is, and we’ve heard this, patients are asymptomatic. So, theoretically consistent with the points you made about HIV, you have no idea whether a person is a carrier and potentially infecting people or not. So, you have to do that. How can you reassure? And you also mentioned fear, the clinicians who are like, “Oh, I don’t know how I feel?” Or even the patients who are feeling apprehensive about, “Well, if I’m going to go in there, am I going to get infected?” What advice would you give?

Dr. Ann Marie Silvestri:

So, I can think back to the 80’s. I have a cousin who practiced in a very small town and I was telling him at the time what we did for infection control in my private office with the universal precautions of today. His answer was to me, “Well, you have to, cause you’re in San Francisco and there’s a lot of the AIDS there.” And I said, “But, how about you? Your patients are more fearful to tell you they’re sick.” So somebody walks in and you say, you asked them the wellness questions of today, “Have you traveled? Do you have a fever? Do you have a cough?” Maybe you take their temp, maybe you don’t. How do you know they’re telling you the truth? So you have to treat everyone as if they may have whatever the transmittable diseases of the time.

In our time today, it’s the COVID-19 virus that we’re scared of, but months from now when hopefully we’re all back to work, we still need to be aware that these are issues. We still need to be aware that the dentist will be wearing a mask. The dentist will be wearing a shield. The dentist will have eye protection that will protect the dentist. But how about how do we protect the patient? Well, again, those same things work, but we clean the chairs in between, we use high speed suction when we’re working on the patient, we make sure that we have a clear field as we’re seeing the patient, and we wait in between before having a patient see the chair. I think the key is constant high-speed evacuation.

Community Health Centers Vs. Private Dentistry

Rolando Mia:

Thank you. So, shifting gears slightly, the San Mateo hospital is a clinic and it’s very different from the private practices and the groups. What’s the difference between that kind of clinic and the CHC or community health centers and the private sector? How would you summarize that?

Dr. Ann Marie Silvestri:

So our clinic is the clinic of last resort for both medical and dental, which means that if you need help, you come to a San Mateo medical center, medical or dental clinic, and you will be taken care of your emergency will be taken care of – regardless. The amount that’s paid dependent on finances. But we turn no one away. For example, you come to a San Mateo medical center dental clinic, which there are five, one of which is mobile. You will be seeing that your emergent care would be treated quickly that day or scheduled to be done.

Now, let’s say you need comprehensive general care. That’s a different story. We are so backlogged. We have so many patients that want comprehensive care that we can’t offer that. And that’s embarrassing to say. We’re good for emergency, but we have a 2000 patient wait-lists we’re trying to get everybody, and this is for regular care. This is not emergent care.

One of the things that I’ve been so lucky to have is to have a medical team that feels dental is important. Our orthopedists do not allow someone to have surgery without having a dental checkup. They don’t start oncology or bisphosphonate or cardiology procedures without a dental clearance. OB patients are given priority. HIV patients are given priority.

So, these people come to the top of the list for comprehensive care, which is great. But you and me who just need regular preventive care can’t always get in. It’s kind of like winning the lottery. We call your name, you come in, and you know, people are anxious to be in there. Yay! The good and the bad is that most of our patients, once they get in, continue with us. So, we’re allowing less new patients to come in because we’re seeing recall patients.

So, we’re working on hiring a hygienist and we’ve hired one with the county. We’re looking at hiring the second. When we hire the hygiene that we’ll keep the comprehensive going. And honestly, my little what do I call it, investment in the Isolite several years ago is allowing this to happen quicker because it’s very difficult get dental assistance. And if suction is important because of keeping everybody clean, whether it’s with the virus or just because you don’t want splatter all over your face, it’s your, you know, it helps, and they can work alone.

Rolando Mia:

Wow. Thank you for that. I love the fact that you will treat anybody for emergency care and it’s very reassuring because there are a lot of people who are underserved and I’m guessing that’s a large population of folks that that you treat there. I have been to your facility and it’s a beautiful facility. So, it’s great to hear. How are you dealing with the backlog now with COVID and only dealing with emergency? Because now there’s a backlog of a backlog.

Dr. Ann Marie Silvestri:

So, one of the things that’s been going on is clinics are all open for emergent care. So, if we had something scheduled that was an emergency extraction or some of those things that we’re talking about, those are still being done. What’s not being done is the everyday filling or that sort of thing. But this is the same problem medical is having. You were not having a procedure done just for the fun of it. You were having it done because you need it. So if something has waited too long, be it medical or dental, it’s going to become emergent.

So, we’re looking at slow openings in all of dental, seeing less patients, bringing them in, giving time in between. We have really good division between our operatories, so people are pretty much separate. They’re not in the same area with each other. One of the things we’re also talking about is having a patient come in one door and exit from a different door.

Rolando Mia:

It’s to ensure the integrity of that process?

Dr. Ann Marie Silvestri:

So they don’t cross each other.

Communicating With Your Team and Patients

Rolando Mia:

Wow. From a from a team perspective, how are you dealing with them? What’s the kind of communication that you’re providing to the providers and to the staff with regard to this whole issue because again, who knows what’s going on? What are you telling them and what are you doing to reassure them that things are happening?

Dr. Ann Marie Silvestri:

Wear your PPE. I think that the general public had no idea what PPE was, personal protection equipment, where as we’ve harping on it for years and now you have the whole world telling you to do that.

Rolando Mia:

It’s funny, it’s something you’ve been talking about forever and now all of a sudden, it’s like, so what’s this PPE? It’s kind of like talking to your spouse. I’ve only told you that for the past 20 years.

Dr. Ann Marie Silvestri:

Yes. And I’ve only been married for 45 years and I still haven’t gotten them feel the trend.

Rolando Mia:

So, shifting gears slightly, you’re also an adjunct professor at UCSF and UOP, one of the things that’s happening right now, is a big issue for the fourth year specifically or looking to graduate. There’s this massive uncertainty because from a procedural perspective, they can’t treat patients in clinic. So, do you have any thoughts, or did you have any insight into what they can do or what’s going to happen there?

Dr. Ann Marie Silvestri:

Yes and no. My position was more that the students came to the medical center and worked with us on our patients. When all this first happened, we did offer the students to come increase days. But I think at this point they’re trying to figure out what to do with them to get their didactics out of the way. I know that you UOP, which I’m a little bit more familiar with then UCSF, is talking about extending their, they’re on a 3-year system where they have a longer vacation in June. That vacation is going away and they will work on it.

They’re talking right now about bringing the seniors in a week earlier than the rest so they can get their didactics done. They’re talking about ways to get them into the clinic. They’re talking about whether working on a typodont is the same as working on a patient, which I’ve said no, but it’s like they’re trying to work on this sort of thing to get it to find out what to do with them.

I mean, I saw something that said we’re all in the same boat. We’re not all in the same boat. It’s more like someone else said we’re all in the same storm. It depends what boat you’re in. If you were going to graduate, if you were going to have some big thing happen to you in during this time, it’s a little bit different. I mean many dentists are not working, they’re not eligible for any other income, and it worries me what will happen with the private dentist at the end of all this. So, I know that the private dentists that I’ve talked to are really doing an upscale job and looking at what they did for infection control. Many are realizing that they did all the right things and they’re even trying to make that more.

Rolando Mia:

Wow. Amazing. What advice would you give to clinicians, especially at this time, who are feeling fear and freaking about the situation that we’re in and whether or not this was the right profession to go into. All of a sudden, we’ve been hearing, “Oh no, everyone always needs a dentists until now when it is shut down.” What advice can you share?

AIDS Crisis and it’s Relation to COVID-19

Dr. Ann Marie Silvestri:

I don’t want to keep mentioning when the AIDS epidemic hit, what were we going to do then. I mean, I hate to just keep repeating this, but infection control is our main way of taking care of everything. But I would say the dentists are very used to doing that. Keep doing what you were doing. I know that they’re putting up shields on desks and stuff like that, that sometimes I wonder if it’s necessary, but I think you give the perception of being better like limiting the amount of people in the waiting room. There’s many people that are having patients, especially if they have kids, the child comes in and the parent waits in the waiting room and they have them wait in cars and that sort of thing.

I know that you’re working with more assistance if you can get them and not seeing as many patients. I don’t want to seem like naive or Pollyanna type, but I think that you’re safe, I really do – I think that we followed infection control. You don’t go out there, how do I say this? Right? You know, you don’t go out and step in front of a bus, but if you’re around it, you take a step back and take the precautions that you need to have. I really think that you will find the dental offices are probably the safest place to have medical care because we’ve been doing it for so long.

Rolando Mia:

I love that message and I think that’s important. So as a follow-up to that for patients who will be viewing this or who are on right now, what message would you like to give them? What’s the message you want to give to the patients out there who are thinking “I’m in pain but I don’t know if I want to go in or not sure what is an emergency if this is an emergency?” As you can see, some of the states are starting to turn on and people are going, “I don’t know if I want to go.” What message would you want to give patients about that?

Dr. Ann Marie Silvestri:

Be smart. If you have pain, it’s not going to go away. Dental is different than any other type of pain or infection or disease that you have. You know, if you have a headache, you can take a pill. You can’t take a pill and get rid of the dental infection. It has to be treated and the longer you wait, the worse it’s going to be. So my advice to a patient would be to assess the situation, to call your dentist, see if they want to see you as an emergency. Trust what the dentist says.

If it’s an emergency when you go in, you will no doubt see the dentist is wearing a mask as they did before, is wearing gloves as they probably did before and is wearing eye protection as they probably did before. And possibly wearing a shield, which maybe they didn’t wear that before, but they are now when they’re working on you.

I just can’t stress how important it is not to have splatter all over the place, you know, but we’ve always watched that. We’ve always done high-speed suction. The low suction just helps you in that you don’t get a lot of liquid in your mouth, but it’s the high speed that takes care of the spray and the aerosol. I just think you need to be aware of what’s going on. Be honest. Don’t say, “No, I’m totally fine. It’s no problem. I’m okay.” Be honest because you’d want your dentist to be honest with you.

Rolando and I met years ago when we put in the Isolite and I was not his easy customer. I needed lots and lots of information. I was spending a lot of county grant money and we had to prove that it was going to work. In retrospect it was a very smart thing for me to do because of the high-speed evacuation that is being talked about all over as the best way to get rid of aerosols, splatter and that sort of thing.

Not to give him a plug, but we have Isolites on all 20 of our chairs and my staff has loved it. My assistants have loved it because I don’t have to stand by the dentist in here, “Can you get this? Can you get this, can you get this?” And patients like it and this area that we’re in right now, the importance of suction and why, I mean we’re putting all this protection not to get the splatter on us or the patient.

Our clinic has also put safety goggles on patients, which is not always done and not necessarily required, so they don’t get spatter in their eyes. The importance of the suction. I can’t stress how important that is today, even more than I thought it was before.

Rolando Mia:

Thank you for that. Really appreciate that. You’re so clairvoyant. You knew this was going to happen. So, as a way to encapsulate everything we’ve talked about I’m going to ask for a closing statement for our session. What is it that you’d like to get across to listeners, to people who are going to be seeing this over the next years? How would you like to summarize what we’ve been talking about?

Reassuring Words to Patients and Dentists

Dr. Ann Marie Silvestri:

There are two populations that I say that can be interested in this. One is the providers, the dentists, the assistants, and the hygienists. Don’t be afraid. Work smart, protect yourself, protect your patients, and you do that with proper PPE for yourself and equipment for the patient.

For the patient, again, be smart. If you have a problem, it’s not going to just go away. Take care of yourself. Treat the issues that you have. Go to a dentist that you can trust, and you see that the infection control is being done. Be honest with each other. If you have the disease, tell the provider, tell the patient, close your clinic if you have to. I mean, I know myself. It didn’t matter how sick I was, I wanted to work. But you can’t always do that. So just be honest with yourselves. And again, aerosol spray, however it gets on you, make sure it’s protected and take precautions for it not to be on.

Rolando Mia:

Really very much appreciate that. It’s funny, there’s a directness and a calmness. Don’t freak out. The sentiment that I’m hearing very clearly in everything you’re saying is, “Hey, you’ve been educated. This is what we do. This is what you’ve been doing. Don’t forget that. Remember, but also don’t be stupid, crazy, or miss things.” If people have questions or want to reach out to you would you be open to having a discussion with them?

Dr. Ann Marie Silvestri:

Yeah. And I have my email and I’m hoping you can see this. Okay.

Rolando Mia:

So yes, thank you. So it’s okay for people to reach out to you, send you messages and all that?

Dr. Ann Marie Silvestri:

It’s fine. I don’t claim to know more than the next person. I’ve just been through this a lot and I just think the calmness and watching what you’re doing, checking what you’ve done before. If you’re a dentist, just don’t be so worried that you have to change everything because chances are you don’t have to. Think about yourself and your patients and the importance of being safe.

Rolando Mia:

So, I have to ask, okay. You don’t seem worried about this. There’s a reassurance, where’s that coming from?

Dr. Ann Marie Silvestri:

I think it’s comes from the years of experience. I mean, I was very worried during the AIDS epidemic. Of course, that was a long time ago when I was much younger, and I remember getting the needle stick during that time. I think this is probably what made me calmer. I’ve gotten two needle sticks in my 45 years of dental. When I got the first one, I was working at San Mateo medical center. I hit the jackpot. He had AIDS, he had syphilis, he had hepatitis. I went through all the precautions and made everybody know that he came to the medical center. Lucky, I was fine. I think that transmission is difficult. If you’re following the right precautions, you’re not going to go sit on top of the patient and breathe in his saliva because he’s got Covid-19. They’re going to get sick.

So, let’s be realistic. Let’s wear the gear that you’re saying the post to wear. Let’s put the things that we can do for the patient to eliminate the amount of aerosols. To reduce the amount of splatter to reduce the aerosol, like I said, the PPE for the provider to wear protection for the patients, suction, whether it’s with a dental assistant, with high speed or with an Isolite. If you want to make your life easy and not have an assistant right by you, whichever way you’re going to do it. These are important.

I also would like to add, I know that it’s not necessarily done all the time, but eye protection for the patient is important too. So, just think about it and if there’s a patient sitting in the chair, in every clinic I’ve worked in the county clinics or my personal office, I always felt that I didn’t mind if I was that patient. It was clean, it was protected and if you can’t say that you feel that way, then you should not be practicing.

Rolando Mia:

Thank you. Thank you for that. I have a theory. I believe that the AIDS, hepatitis, syphilis, all of those diseases that were in that pinprick came into you and your body said, “Uh, No. Grabbed it, threw it out.”

Dr. Ann Marie Silvestri:

Plug for our organization to the San Mateo medical center takes care of everybody regardless of their ability to pay. We have San Mateo County health foundation, which has been wonderful, and obtaining PPA for the group and all that kind of stuff is supported us over the years. What I’ve noticed in the difference from going from a private practice to the community practice is that we have infection control people there that keep us up to date on stuff. That didn’t mean that I didn’t have to. I mean our infection control department knows nothing about dental of love. We’ve worked together. So that’s the importance to me is work together with the resources that you have.

Rolando Mia:

Thank you. That is absolutely wonderful. This is Dr. Ann Marie Silvestri. I love the calmness and the focus. She clearly knows what she’s talking about and I very much appreciate that. If you liked this content or if you have any questions, please feel free to reach out to her. She gave email. She’s been a fantastic resource for us, and I especially like how you know, no bones about it. That’s so cool. If you like this content, please share it. If you have any additional information or if there are topics that you’d like us to talk to with our clinicians and our guests, please let us know. Thank you so much.

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