Infection Control: An Oral and Maxillofacial Surgeon’s Perspective





By Lexi Marino February 2, 2021

In this episode, we met Dr. Jay Reznick, Oral and Maxillofacial Surgeon to discuss infection control from a surgical perspective and how the dental community, outside of the surgical sector, is having to adapt.

Watch this video to learn the following:

  • How does COVID-19 spread and which protocols should you have in place for a safe practice?
  • Don and doffing your PPE – how to properly to remove your medical attire
  • Negative rooms and how to create the concept with dental isolation

Rolando Mia, from Zyris, is the host of our series, Dental Voice. In this show, we focus on the latest news, topics, and conversations happening in dentistry and assess differing views across the nation. In Season 2, we’re focused on, “What’s Working and What’s Not”, where we’re debunking myths by assessing trial and error since the start of Covid-19.

Transcription:

Rolando Mia: Hey everybody. Welcome to “Dental Voice” season two with Zyris. My name is Rolando Mia, and today I have a really special guest, I’m really excited to spend some time with. The person that we’re going to be hearing from is Dr. Jay Reznick.

Dental Voice is about hearing from clinicians, understanding the perspectives that they have, the issues that they’re facing, and how they’re navigating through those issues. So, I’m especially interested in hearing that from Dr. Jay. So, Dr. Reznick. He is an oral and maxillofacial surgeon. He received his DMD from Tufts. He got his MD from USC. He did his general surgery at Huntington Memorial Hospital in Pasadena. Then, he trained in oral and maxillofacial surgery at Los Angeles USC Medical Center. So from an understanding of all of the issues related to infection control, with regard to medical and dental. So, Dr. Jay, how are you?

Dr. Jay Reznick: Good, Ro, how you doing? How are things up in Santa Barbara?

Rolando Mia: Very well.

I want to jump into this, the education, and the knowledge that you bring to bear from the medical as well as the dental side, one of the big issues that constantly comes up is the issue of infection control. In addition, it’s this hierarchy of controls, as well as breaking the chain.

From your perspective what are things that dentists should really keep in mind with regard to what measures to put in place. So what advice would you give people with regard to that based on what you know from the surgical side?

Dr. Jay Reznick: Well, I think one thing to understand is that as dentists we have sort of been ahead of the curve in infection control starting with the AIDS crisis in the mid ’80s.

Before that it was rare for dentists to wear gloves treating patients. I had some instructors in dental school who weren’t wearing gloves when I was there. And it was very difficult for them to make that transition, but now we started learning about bloodborne pathogens that became part of our education. We became very good at taking universal precautions with all our patients whether we knew if they were infected or not. With COVID-19 things are a little different because this is not something that’s transmitted by bloodborne, or a very minor extent.

It’s basically airborne, aerosols, fomites, droplets, on surfaces, in the air. So the whole risk becomes much higher if we don’t address how to minimize the risk. Certainly, this has been an epidemic of epidemic proportions because it’s basically taken over the world, or a pandemic of epidemic proportions because it’s taken over the world in a very short time, and completely changed everybody’s way of doing everything.

I mean, the world is upside down right now, and we’re not sure when this is going to end. Currently, the numbers are trending down a little bit at least in the U.S., but who knows what’s gonna happen? It’s really important that we understand how this virus can be transmitted to person to person, and doing everything we can because we’ve got to minimize the risk when we’re in our offices to our patients, to our staff, and also to yourself, you don’t want to come home and get your family sick, or one of your parents. It’s really critical that we understand how it’s transmitted.

We are very diligent about what we do, and that’s, obviously, masks, gloves, but now we’re adding gowns. We’re adding N95, we’re adding face shields. We’re adding all kinds of equipment to reduce the amount of aerosols and sprays, which have been rather expensive to bring into our offices along with air purifiers, but we have to. In order to be able to practice and survive, we’ve got to do these things because without them who knows in the next wave whether we’ll be able to practice if we don’t have them. It’s always best to practice defensively.

In this regard, preparing your office for as if an Ebola patient is coming in is almost what you got to do to reduce the spread, and risk to everyone who’s in your office. And then, of course, outside.

Rolando Mia: There’s an actual process for putting on and taking off PPE, and all that type of stuff?

Dr. Jay Reznick: Well, as a surgeon having spent what? Four years of surgical training, we’re pretty well-versed in aseptic and sterile technique. We know the proper way to put on our masks, and our hair covers, our gowns, and our gloves, and the proper way to take them off so we don’t infect ourselves when we’re taking all these things off.

It’s difficult for general dentists, and other specialists who haven’t had this training. It’s something new you have to learn, something completely foreign that’s got to be learned, but it’s really essential because you want to make sure that you’re protected before and during a procedure.

Again, it’s important that you don’t contaminate yourself taking this protective equipment off because it definitely will have some aerosol, some splatter on it. So you got to protect yourself when you take it off. So you have to know the proper technique to both don and doff your PPE.

Rolando Mia: Doff?

Dr. Jay Reznick: Yeah.

Rolando Mia: So, wait, that’s the technical term, don.

Dr. Jay Reznick: That’s the technical term, yeah. Don is to put it on and doff is to take it off.

Rolando Mia: So it’s interesting, I’ve never heard that before. Well, because personally I haven’t been exposed.

When you look at the population of clinicians in the dental industry who don’t have the surgical background, what are some of the key things that you just have to understand with regard to doffing, I guess, your PPE?

Dr. Jay Reznick: Well, the biggest thing is if you take off your gown you have to take off your gown with your gloves on, and basically pull the gown off. Then when you have your gloves, it would be easier to demonstrate if I had some gloves here in my studio, but you will remove let’s say your left glove by grasping it and removing it.

So, you’re touching a glove surface to another glove surface. And then once you have got the one glove off, which you’re holding in this hand, then you take your unprotected thumb or fingers, put it underneath the glove and pull it down. So you’re basically glove to glove, non-glove to non-glove, and you take it off and you throw it right away, but the first thing that comes off is your gown.

Rolando Mia: I love that. When you think about the chain of infection, and how you break that, one of them is minimizing exposure, and you don’t even really think about it because up until this point there really hasn’t been anything as virally as COVID. Although, I don’t know, hepatitis, any other.

Dr. Jay Reznick: But, again, it was bloodborne, so you knew how you got it.

You could still go out to dinner. You could still congregate in groups. You could still go to concerts. You could still go to dental meetings.

Rolando Mia: Right.

Dr. Jay Reznick: Even more so than the flu, or, for example, the SARS-1 virus was much more contained, or MERS, the Middle East Respiratory Syndrome virus were much more containable than this coronavirus, SARS-coronavirus-2, which is the proper name for the virus. COVID-19 is actually more of the syndrome, but the virus is SARS-coronavirus-2 is that it can be spread in the air, and it spread so quickly throughout the world it really took us all total by surprise.

So, that was one of the issues that occurred early on is we’d never seen anything like this before. I think it was even more rapid than the 1918, 1919 flu pandemic because in order for it to come to the U.S. people came over on boats, and there weren’t as many people coming over. And now with the global economy, and planes flying back and forth, and it’s so easy for people to move around the world. The other thing is that you can be completely asymptomatic.

You could have contracted the coronavirus, and be completely unaware, and then travel to the other side of the world, or get together with your family. And all of a sudden you have now infected many, many people, and it grows exponentially because those early days when you first get infected are actually when you’re the highest risk of transmitting the disease to someone else, that’s when you’re most infective.

Rolando Mia: Interesting. The big thing that everyone is talking about, and you touched on it are aerosols. Aerosols in public places, aerosols even in your home, aerosols in the dental practice.

The reason I’m asking is there’s this whole issue that’s been thrown around about negative pressure rooms. And when you think about a negative pressure room in a surgical in the hospital, all of them are negative pressure, but that’s not something–

Dr. Jay Reznick: Actually, not all of them.

Rolando Mia: Or a lot of them, I apologize.

Dr. Jay Reznick: For orthopedics, especially hips and knees, and those big joint replacements those are always done in negative pressure rooms, but your typical procedure is done in a standard operating room, but, yeah, the negative pressure I actually installed two units in my two surgery rooms, which were not inexpensive, and we were going to, actually, it’s 99.99% HEPA filter with then UVC.

Then we could vent it up to the roof in our building because we’re on the top floor. And we actually brought out an HVAC guy to hook all that up. And he said that the units I bought were so efficient at cleaning the air, we actually don’t need to vent to the outside.

Rolando Mia: Wow.

Dr. Jay Reznick: Basically, completely pure air goes around. I think the two units I got will clear 1,000 square feet per hour, or something like that. So they’re still pretty massive. And then we got regular air purifiers throughout the rest of the office, so we got about 15 of them.

Rolando Mia: Wait a minute, I love the clarification. Not everything is negative pressure. So how important is this context of negative pressure in the dental practice?

Dr. Jay Reznick: Well, again, negative pressure is taking the air in a room, and completely sucking it out. And then new fresh air comes in from outside. So as long as you’ve got a really efficient means of cleaning the air. So if you’ve got like an in-line HEPA filter and UVC system in your ventilation system in your office, or you’ve got HEPA filters cleaning the air all over your office, the problem with UVC is its radiation, it’s ultraviolet radiation.

There are questions about having UVC radiation in your operatories, or in your office, and is that dangerous? And that’s why some people put them in their air duct systems, but then there’s the issue of duration. The air has to be exposed to those UVC lights for a certain period of time in order for it to be effective for killing viruses. So the UVC is a little tougher. That’s why we went with these units where it’s all in one. They’re a little more expensive. They run anywhere from about $1,500 for an inexpensive one. The ones I put in my OR were $5,000 each, in addition to everything else. It’s been expensive getting back to work, but we had no choice.

Rolando Mia: No, well, absolutely. And everything is highlighted around eliminating that. I know you use our system.

We’ve been told that our system generates negative pressure in the mouth do you see that, or do you feel that that’s not a big deal?

Dr. Jay Reznick: Well, it definitely creates negative pressure within the oral cavity and reduces on aerosols. And, basically, you have less fluid flying around because the Isolite® will isolate the area, and has built-in suction. So it’s really reducing the total amount of aerosol that can be generated, but, yeah, it’s also vacuuming away a lot.

There’s all these other negative pressure systems that people are selling for dentistry where there’s like a little cone above the patient’s face, and it sucks out and purifies the air. Those are also very effective. For surgery, we can’t really use those because we’re generally standing up in front of the patients. We have them under general anesthesia. So we have to have easy access to their whole head. All these things that you do are effective.

Rolando Mia: So it’s a matter of layers.

And then, of course, completely wiping down your rooms with true virucidal agents. Was it hypochlorous acid?

Dr. Jay Reznick: Yeah, hypochlorous.

It’s like a peroxide, but, anyway, I can’t remember everything. So having that to wipe down all your surfaces. You can use bleach if you don’t have anything else to wipe everything down, although it will make your office kind of smell even if you dilute it. Is it carbolic acid? Anyway.

Rolando Mia: Hypochlorous is one of the ones that we’ve heard.

Dr. Jay Reznick: I think it’s hypochlorous, yeah, which is basically kind of like a bleach, but a little different. So you have to wipe down all your surface, and you have to be aware that the coronavirus will remain viable on different surfaces for a different duration of time.

So something like the metal, the counters in your office it can live up to two to three days. If you’ve got more porous surfaces like cloth, or your surgical gowns it lasts much less time. Interestingly copper, which is a metal, tends to be virucidal and bactericidal. The virus tends to live much shorter times like less than an hour on those surfaces, but we don’t have a lot of copper laying around our offices unless you like that look.

So you just have to be diligent, and wipe down before and after every patient, as well as at the beginning of the day, at the end of the day. And so we’ve dedicated an extra 15 minutes for every procedure we do to wipe down the rooms. It reduces the number of patients you can see in a day for sure, and that’s another thing. Our schedule has been pretty busy for the last few months, but we can’t see as many patients per day because we’re restricted by this extra time to clean. So instead of 30 minutes for a procedure it’s now 45, and you get a couple of those in the day.

I can do two less surgeries, see two fewer consults during the day because we have to space patients out. We’ve got to make sure there’s not too many people in the office at once. And it is a burden, but what choice do we have? It’s either that or sit around and do nothing.

Rolando Mia: So for the clinicians, for the dentists, the other clinicians, hygienists, dental assistants, from your understanding from the surgical suite, and marrying it to the dental office, what would you say are the top one, two, or three things you absolutely need to not do, or you have to do?

Dr. Jay Reznick: Well, I think you definitely need to protect other patients that are coming into your office. So wiping down all surfaces, and having air purifiers in your consultation rooms, or procedure rooms, and then protecting yourself if you’re doing a procedure, which generates some aerosols which is pretty much everything we do. That’s having the N95 mask. We actually use an N95 with a level two on top of it because you know how difficult PPE is to get. And so we make our N95 masks last for a couple of days by covering them with a surgical mask that we change pretty much every day.

Then we have a shield on top of that, which we change like every two days. We wipe it down and change it every other day. So at least that I think having your hair covered is a good idea. Definitely having a full-length gown, and gloves that come up over the gown are good to protect you. Knowing the proper way to put on and take off the PPE.

What I can do is on my educational website, onlineoralsurgery.com I’ve got some videos that I recorded for one of the companies I was working with, actually, the implant company to demonstrate proper aseptic technique. I’ll actually put those on the website, so that anyone who goes to onlineoralsurgery.com can view those videos on donning and doffing. I think that will be really helpful to everybody, and get as knowledgeable as you can.

Get information from reliable sources. If you’re gonna get stuff off the internet get it from reliable sources. And one source that I get to keep up on everything is a website called VuMedi, V-U-M-E-D-I.com Every day they’re adding lectures about anywhere from 10 to 20 minutes from epidemiologists, and virologists, and infectious disease experts, and pulmonologists, cardiologists, from all the major universities. There’s a lot from Stanford, Harvard, Penn.

They give you the up-to-date, up-to-the-minute, most relevant, scientifically-based information, and clinically-based information to go by. Don’t go by the news. CNN, and MSNBC, and Fox News, don’t listen to that, but really reliable sources are really critically important. And, of course, make up your own mind about what you think is the best thing to do for your office. And I know the mask laws are different from state to state and community to community, but I think, wearing a mask as horrible as that is, I hate wearing a mask, wearing them when you’re in the appropriate circumstance. So if you’re indoors, you need to wear it.

If you’re outdoors by yourself, or with a family member, and you’re at least six feet away from others you don’t need to wear a mask outdoors because it’s not gonna make a difference, but definitely indoors you need to. And when you’re around other people that are not part of your family because the three things that really dictate whether you are going to get infected, or pass the infection if you’re asymptomatic are dose, which is basically how infectious you are, or they are at the time.

The proximity to that person, and the duration that you’re around them. So if you are, for example, outside walking, and someone is coming at you from the other direction who has coronavirus, they’re in the early stages asymptomatic, and you just walk past them in a brief second, your risk even if neither of you are wearing a mask is like less than 0.05%, okay? So it’s pretty minimal because it’s a very brief encounter and it’s outdoors.

Whereas, if you are indoors with someone, let’s say you’re in the bank, or in an office setting where it’s enclosed you don’t have the fresh air constantly circulating, where you have to be within six feet of each other, and you’re within six feet for about at least five minutes. Then you have about a half a percent chance from each of those encounters. And, of course, they accumulate of catching the virus.

So, for example, someone in your household who you’re constantly exposed to day in and day out, it’s much higher like 10%, or if you’re vulnerable even 20%. And so there are different risk factors that make you more susceptible to catching the virus, and becoming sick, that you’ve got to consider too. There’s so many factors that you need to consider. That’s why getting real kind of legitimate science-based and clinically based-information is so critical now because there’s a lot of misinformation out there. Conspiracy theories and all that kind of stuff that we have to get past and wade through.

Rolando Mia: The idea of duration I’d heard that, but a quick fly-by not as big a deal, but the longer you’re together, the proximity that’s another one.

Dr. Jay Reznick: Yeah, it goes up.

Rolando Mia: It makes sense. Now, when you have patients, that just don’t believe, or don’t want to comply. How do you deal with that? How do you manage it?

Dr. Jay Reznick: It’s pretty easy from my standpoint because my paramount responsibility in my office is to protect the patients who are there and my staff. And, of course, myself too, because I’m no good if I have to quarantine for two weeks, or I get sick enough that I can’t practice anymore, or I’m gone for months.

It’s easy in Los Angeles, in California because there’s an emergency mandate from our governor, and from our mayor that everyone who enters any indoor space, especially, medical office must wear a mask. They must have their temperature taken upon entry. Period.

They must answer a screening questionnaire before they can be seen. They’ve got to use a hand sanitizer. All those things are required. And so if a patient doesn’t want to comply to that how do you deal with it? So first thing we do is whenever a new, or returning patient makes an appointment, we tell them that this is our office policy mandated by the city of Los Angeles, and by the state of California and we’re abiding by it. So expect these things when you come in.

If you can’t accept those then, unfortunately, we can’t see you until this blows over. If they come in, and they refuse to wear a mask anyway after being told you can refuse to see them unless it’s an emergency. If it’s a true emergency, and there’s nowhere else they can be sent, then you need to treat them, but you need to modify what you do.

So if we have a patient, I actually have one who absolutely refuses to wear a mask, will not fill out the questionnaire, won’t get her temperature taken. We said, “Okay, well, here’s what we’re gonna do. You have to be seen after hours when no patients are here when I have a very minimal staff. You will need to use the hand sanitizer. You will need to complete the questionnaire. If you don’t want to use our thermometer you can bring your own, but it’s got to be used in our presence.” And, of course, a lot of these patients will claim they have a medical condition that prevents them from wearing a mask.

So what we’re requiring is have your physician send us either email or regular mail directly from their office a letter stating what medical condition you have that will prevent you from wearing a mask, and why wearing a mask is detrimental to your health for a brief visit or a 30 minute visit.
Once we have that, then we’ll appoint them, but they also have to follow the other rules. Because, again, if the patient wants to get sick that’s fine, but the problem with it is that during that two, three-day asymptomatic carrier period you can easily infect 10, 20, 100 people without knowing it. And that’s where the danger is. And that’s why this pandemic has become a pandemic, and so quickly.

Rolando Mia: Wow, I love the context that you built around it. You either comply or you don’t, we’re setting these rules. You either do them, or you don’t.

Dr. Jay Reznick: There’s no obligation to treat them. It’s not considered discrimination. And I definitely have spent a lot of time researching the legal opinions. It is not discrimination because you’re not saying you won’t see them.

You’re saying, we’ll see you as long as you follow the emergency health guidelines that have been mandated to us. And so it’s not refusing to see them. So it’s totally different. It has nothing to do with the Civil Rights Act of 1964, or Americans with Disabilities Act, any of that. It’s, basically, you’re happy to see them as long as they comply with these mandates.

Rolando Mia: You have such a wealth of information. So much of it is so practical. For people who want to find more out. I love the website you have, but you do have other resources that people could utilize?

Dr. Jay Reznick: Like I said, VuMedi is great. And I watch a couple of videos on there pretty much every day to stay up-to-date on the latest. The CDC issued some guidelines, but they’re not hard and fast rules. The dental associations do the same. One of the problems is there’s no absolute guidelines.

Rolando Mia: That’s cool. You mentioned earlier, before we got on, you’ve got a couple videos, or something that you’re gonna make available to the public.

Dr. Jay Reznick: Yeah, I’ve actually got a couple of podcasts that I did on my website. One of them is with Dr. Cathy Hayes, who is an epidemiologist. I believe she is head of now Massachusetts State Dental Public Health Organization. She’s got a master’s in public health. She’s got, I think, a doctorate in public health. She’s brilliant, and she’s trained at Harvard, and Tufts and BU, is on faculty at Harvard. So we had about an hour or so talk about COVID-19 this new virus, and what was known at that time a couple months ago. And then I’ve got another podcast that’s with Dr. Sam El-Ebrashi, who is a prosthodontist up in Portland. And he is very well-versed in how you modify what you do in your practice, and what to do in this new age of COVID-19. So they’re both really great talks. And so I’ll make them available on the website. All you need to do is register. Get the 30 day free trial, and you’ll be able to watch those videos. So really good supplement to what we talked about today.

Rolando Mia: Cool, so, first of all, I so appreciate you spending time. If people wanted to get in touch with you, or ask you questions, or wanted to visit what would be the best way for them to do that?

Dr. Jay Reznick: Probably the best way is to just send me an email. And my email address is Jay, J-A-Y @onlineoralsurgery.com all one word, and it will go to me directly, and I’ll answer you.

Rolando Mia: Awesome.