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 interviewed Michelle Strange to get her perspective on infection control and how the reduction of aerosols in conjunction with biofilm management will dictate the future of dentistry.
Watch this video to learn the following:
- Infection control – what we’re forgetting
- Dental hygiene and proper PPE/protocol
- Upper respiratory illnesses in relation to aerosols
- Ways to stay in touch with patients and employees during this time
- The importance of biofilm and bioaerosol management
All right, here we go. Good afternoon everybody. This is Rolando Mia with Zyris. I have a special guest today. Really excited to spend some time to speak with her. Everybody, if you don't know her, you will know her by the end of this. This is Michelle Strange. We met a little bit ago and before I start asking you questions, I just want to say a couple of things.
First of all, Michelle has an incredible passion for dentistry, for her craft, for hygiene, and for basically anything dental. She considers herself a dental nerd. She runs a podcast “A Tale of Two Hygienists” where I believe she's got over 200 or so plus episodes and they are incredible. It's a wonderful forum and you can hear from so many different people.
In addition, she lectures, she's written a whole host of different articles that I've had the pleasure to read and now talks about what's going on here with very relevant material to what we're doing today. In addition, she is a serial workaholic entrepreneur. Loves this industry. She's, got triviadent.com she works with Dr .Tony Stefanos. She works with virtually everyone in the industry that has a space in here we’re very thrilled to have her here. So Michelle, thank you and welcome them.
Yeah, no, thanks for a great introduction and it's so true. I am obsessed with this profession.
What I'd like to do over the next you know, 20, 30 minutes or so is basically spend the time, the purpose of this session is to talk to you specifically about something that you've been passionate about you've been very much a champion of and that has to do with infection control specific to dentistry, but it's also across the entire spectrum of all of the different areas of dental procedures.
Could you please give a summary of how you would define infection control in dentistry and its effect on things like aerosols, viruses, diseases, all those types of things. How would you summarize that for us?
Infection Control: The Beginning
So, I would say I’m new in infection control, I've been dabbling in it for awhile. I've always been a little bit of a clean freak especially and I've worked in surgical practices. I started out as an orthodontic assistant on the job trained where I didn't know what to do and I probably did some horrible things. But luckily it's not like a lot of blood, even though saliva is infection, there was not a lot of blood everywhere. And so, I had some horrible infection control practices and again, I didn't know what I didn't know. And then I went to hygiene school and my eyes were wide open and I had a quite a few faculty members that, you know, may and let you get away with the darn thing.
I learned very good infection control procedures. And then I went into a surgical practice where I really had to implement that because we were doing major jaw surgeries and implant placements. Then I got to do surgical assisting and the dental hygiene side of it.
I went into another periodontics practice where the periodontist had just amazing infection control. He took the, the neat freak, clean freak that I was to another level. Then, I went to a course very early on for continuing education and Olivia Wann was the speaker. She’s been on my podcast a few times. She doesn't know how much she intrigued my passion for infection control, even though I don't know if I've told her enough that she's kinda the one, but I heard her speak and she did it so great and so relatable.
It was probably the first time that I wasn't like sitting through it feeling like it was just so dry and oral, horrible. Like, “Ugh, I got to get through it.” And I was like, “Oh my gosh, I, I love infection control, I want to talk about these things.” But it's been quite a few years to get to that because I think that was probably 12 years ago and I really, kind of diverged a little bit and went into the world of dental implants, home care, and biofilm management at home.
I did that for a few years and I started doing some side research for a company that is now on the market and actually kind of popular right now and I really delved into the aerosol research for them, looking at the aerosols that we produce in dentistry. When they gave it to me, I was flying with it. I was flying with these nose filters - I was getting sick in the very beginning and I'm on planes way too much and was like “I'm gonna start wearing these nose filters.” And then I was like, “Yo, this would be amazing for dentistry.” And they're like, “Really? Do you think dental people would want this?” I was like, “Are you kidding me?”
But again, I'm the weirdo in the office. That's watching people touch things with gloves versus clean hands. I'm like, “Wait a second, what's the protocol here? Are we touching with things with dirty hands or touching things with clean hands?” So me being the weirdo I was, they were like, “Is it just you that would wear it or would every dental professional wear it?”
And I was like, “I don't know, let me do some research?” And that's kind of when I started delving into aerosols and spatter and spray and how we're the biggest producers of that. So I've been kind of not so much in infection control as much as I am now cause I'm working on my credentials for through OSAP and DANB to get a real certification to be a provider of infection control training and OSHA. But I was kind of dabbling in this aerosol world and I was like, “This is insane! Why don't we talk about this more?” So, I eventually got a little bit of a voice in the profession and I've been preaching it for a while. I don't know if anybody was really listening a few years ago.
Spatter Vs. Spatter: Infection Control
Well it's, it's interesting, I've read several few articles and the context that you have around infection control is so comprehensive because it involves understanding the process. It involves all the different types of diseases. And here's the thing too. I believe you're clairvoyant because there was an article that you wrote a year ago before this entire crisis that we were getting into. And in addition to talking about bacteria, in addition to talking about airborne biologics, in addition to talking about all of the different kinds of diseases that are out there, you actually mentioned straight out the coronavirus, SARS, and all that.
You also have been very much a proponent of educating around this idea of aerosols. Help me understand hygiene is a key area that you are practicing and it's one of the areas where I believe from a dental perspective the majority of the procedures have an ultrasonic scaler in there. And you know, I even heard that people are being told not to do that. Help us understand the aerosol issue in hygiene and also clarify spatter and splatter. What's that?
So, I actually did get a really good way of describing this. A spatter versus a splatter. So you have a blood spatter and that's what lands. So splatter what comes out before it lands. And once it lands it's spatter. So they're essentially the same thing. One's just airborne and being and what's the word? Like? Yeah. I can't find my word, but yeah, it's in the world before it lands and then it becomes spatter. So you have a spray, splatter, spatter. It gets a little confusing.
Aerosols and then aerosol. Some are heavy, some are big, some are like large microns. Then you get them all the way down to teeny, teeny tiny microns of like anything lower than 2.5 microns is considered very small. And so anything above a 10 is considered a little bit larger.
And so this gets a little, like if you're not diving into it to learn it, I mean getting into the nuances in the words it feels very nebulous and you're like, “I don't even know what they're talking about.” I had to write a chart at the beginning and tell myself, “This is this size, this is that size.” It's a little much.
But you know, hygiene, it's a creator of all kinds. I mean every particle of every size air, because we're doing air water, we might be doing polishing with pumice, we might be doing air powder procedures, we might be doing ultrasonic. There is just so much, even somebody just spitting their pre-procedural mouth rinse in the sink or if you're having a cuspidor - the door is that little sink that used to sit next to it. Right. I didn't even, I've never even seen it. I'm never in practice with one ever. That's like not a big popular thing in Charleston, South Carolina where I'm at. Even when they like spit into that, that creates all kinds of spatter. So it's a thing that we really need to be concerned about.
Bloodborne pathogens is 100% an issue. But I think we’re all pretty good about blood borne pathogens because of AIDS, but the thing I feel like gets forgotten is aerosol management and aerosols standards. We do have these engineering controls that are high volume evacuation and that we should be using those to control aerosols.
I learned with Magnetostrictive, that was the very first thing I used and then when I went into my periodontics practice, the hygienist that was there with me and was doing the full-time stuff, she used the prophy jet all the time. And I learned to love it. So I used every single patient for, I mean a strong decade of my career, Prophy Jet followed by Cavitron, followed by hand scaling. So I was creating aerosols and I used to have the face shield and my face would be just dusted with all kinds of stuff.
Recognizing Upper Respiratory Infections
I also suffered from a ton of respiratory infections and which is kind of why I feel like I am very evangelic about this, especially with hygienists wearing the proper PPE, the proper mask and the level for what they're doing and using high volume because I suffered from probably minimum of 6 sinus infections a year. Bronchitis. I would get Laryngitis at least 2 to 3 times a year with my, which my patients always commented on, “Great, you can't yell at me about my toothbrushing now.” And I'm like, “You're right. I can't even speak to you.” So I was suffering from it and I honestly, I didn't know what kind of mask I was using back then. I was unaware.
These were not things that were brought to my attention on a regular basis. Maybe in my one CE that I would take every one to two years but that was it. I was definitely guilty of reusing my mask. I was definitely guilty of probably cross contaminating myself quite often. So all the things that I talk about, it’s not because I'm so perfect, I didn't do them. It's because I'd suffered from all the things that were occurring because I was doing these things.
I definitely talk about them because I think upper respiratory infections are huge amongst dental professionals. And there's these studies out there that people have been doing about aerosols and idiopathic pulmonary issues that adult dental professionals have. But no one's really talking about it at the same time. So, but you know, it's not sexy. It's not lasers, it's not implants. It's not, you know, the composite that makes your restorations better. It's not sexy and fun. It's like, “Oh gross. Why do I want to talk about personal protective equipment?”
You know what, Michelle? I believe after everything that's going on now, when we're through this, your life is going to change because there's going to be a lot more attention to it. You mentioned HIV and it's one of our clinicians, Dr. Hirsch mentioned that like that entire situation, it was a paradigm shift after that. I believe that the same is happening now.
You mentioned, upper respiratory infection - that's not just with your hygienist, that also occurs with the dentist, with the numbers and the staff. How would you, if you were to look at it, we have a lot of listeners here and people are going to review this after, what should people be doing now and then where do they need to eventually get to? Would you give us regarding that?
Well, I would definitely say take whatever I say with a grain of salt now cause in an hour it could very well change because we're just learning so many things so rapidly right now. I hope no one is seeing dental hygiene patients at the moment because that just seems dangerous. I would say if I had looked at like what we should have been doing prior to this, you know, before we went into a shutdown, I mean high volume evacuation every time you're using any kind of ultrasonic air powder.
I would even say your pumice and stuff too, because that just spins around and throws it into the air. I mean, granted, those are heavier, so it's going to land and then you can deal with it with your environmental infection control. Or it can land on your mask and you're just gonna remove it and take it off.
Those aerosols that linger in the air, for me, it has always made so much more sense to get them before they get out past the mouth and into the air and into the operatory where they can float around and go into the hallway or just be hanging out there until the next patient walks in.
That’s thing I didn't understand, I was like, “I'm trying to explain to you all that these things linger.” So that person had the flu and now you know, I'm walking. So that's the thing is like we always kind of put this stigma on people that weren't like clean, like, “Oh they wouldn't have anything communicable, they wouldn't have, you know, HIV or they wouldn't have Hepatitis C” but what about the damn Flu? The common cold, the coronavirus like is a part of the common cold line. So what about that? Like why wouldn't I be concerned about those little things?
Also, I think when we aren't using high volume, they breathe it in. So like we're just throwing it in. We're forcing them to breathe through their, well, they should be breathing through their nose anyway, but because we're in their mouth, we're definitely forcing them to only breathe through their nose and they have no option but to breathe in all of the junk that we just brought out of their mouth. And it takes it into their upper respiratory track.
And you know, I couldn't find any like super hard data on that and like science and no one's really reporting to the CDC on if they get a cold when they go to the dentist. But, you know, we have a lot of those anecdotal experiences where patients come back and they're like, “I get a cold every time I would come here.”
There's one lady that would take gauze over her nose during her dental appointment. All these hygienists were like complaining, “What kind of crazy person is this?” And I'm like, “She might be on to something.” So I think high volume to go back, I'm sorry I digressed, but to go back to that, I think high volume 100% should be used and it's awkward and I get it. You gotta work through that. You gotta train through it. Definitely proper PPE. Pre-procedural rinses like getting that patient to rinse and decrease that bacteria load as much as you possibly can.
Continue excellent environmental infection control and barrier wrap everything you possibly can so that you don't allow cross contamination.
Wow. Thank you for that. Appreciate that. It's, kind of this idea of taking what has been done and being very much more aware of it. Where do you see this going eventually? Or what are your thoughts? You mentioned earlier you said the term biofilm and I believe biofilm is something that grows when things land on it. What is that?
Well, biofilm is what is in the mouth. That's what we're contending with. That's what's creates a lot of the oral diseases that we’re trying to prevent or fight against and bring them to a level of maintenance or secondary prevention. So, you know, a new terms which I love that Dr. Tom Larkin talked about was a “bio aerosol”. So it's the bioburden, the bio bacteria, the pathogen, the germs, if you will, that are in the aerosols. So even our lasers and that we do there's that plume that smoke that comes off of it.
They have found that there's, living, pathogens and viruses in those. And so we’ve got to control those. So from here on out, I mean, if I had a crystal ball and I can make some guesses cause I don't really know where this will absolutely go, but I think we're going to really look at 100% high volume evacuation, which Washington state was moving in that direction if they haven't already passed it. They were pretty close to it. Where if you're using ultrasonics and anything creating aerosols and splatter, you should be using a high volume evacuator and wearing the proper PPE - minimum of a level three mask.
I'm to a point where I just don't even understand why you would have a level one mask. I mean I just don't even know why. I guess if you're like looking at real pennies compared to like, you know, “If I choose this one for x-rays over this one and I saved like 10 cents.” I don't know, but I'm I tell hygienists, “If this is the issue and you're having a hard time, like getting that level three mask, a box is not that much and honestly it's less than a copay at a doctor for when you get sick.”
I mean it's a copay and it'll last you. So just prevent the problem that you could probably then take to your family and get them sick as well. So I think minimum level three, possibly N95 - thing that about N95’s is that I think everyone, like Crosstex has ones that are actually more like ear loops, so they're not like the ones that are like suctioned to your face. But my God, people lets to learn how to wear those masks properly.
Don't put them on your chin, don't wear them below your nose. They are meant to fit properly along your face. I would like to see that we'd go to fit testing for our mask to make sure they fit our face properly. All this twisting of the ear loops to make sure you get rid of that gap, like no. If you have to do that, you gotta find a mask that fits your face properly.
Then, I think even looking at things like HEPA filters and cleaning the air a little bit better in your operatories and just, you know, managing your surfaces and barrier wrapping things a little bit better and doing better environmental infection control. I do believe those are very few of the future things that we're going to see.
Thank you. That's incredible. We are seeing a lot of those types of things. There was a podcast that was recently put on by DentalTown.
Mmm. Yes. Saw part of that.
Constant evacuation. And you also mentioned how important that is with regard to managing the aerosols with regard to managing any of the the bio load or I mentioned the different sizes of aerosols that are out there. I think that's all of that seems amazing and I think that's cool. You currently are still, well you were up until this point until everything was shut down, treating patients for hygiene, is that correct?
And the focus of this is around that, but it's also the advice, it sounds like that you're giving us is just permeate also through to the dentists also through to the dental assistants and does it even include potentially people in the, in the office and the rest of the staff?
Well I think also so we talk about patient care, but there's also a lot of aerosols produced in the lab and we have to think about that as well. And I know you don't like have a high volume over there, but wearing proper mask and protection and maybe even having an evacuation system somewhere or at least better filtration because like when you trim your models or you're carving out that denture and you just got all those acrylics flying in the air.
When I was a dental assistant and I would do nightguard repair and delivery I should say, I remember having to blow my doctor off with air water syringe cause he would just get dust all over him and I'm just constantly like blowing around like, you know, just cause I'm just sitting there waiting for him and that patient can be breathing that in you know.
This is the other thing too, I would say because this, I was guilty of this and I know my front office was as well, but if we were working with a sedated patient and maybe the front office would come in and be like, “Hey guys you know, your next patient is running 15 minutes late”, and we're just in there like cauterizing doing lasers and stuff. And they're like, “Oh, okay, cool.” I mean they're just breathing in that stuff and we know aerosols don't just stay there, they're floating around especially don't have really good evacuation and filtration and you get the air blowing, it's going to go down the hallway. So yeah, you got to do all these things, not just you doing the procedure and the patient in the chair, but for your team as well.
The Importance of Continuous HVE: Infection Control
That's great advice. And it is again, a paradigm shift in the way people are looking at infection control and how to manage it and how to ensure that those, that bacteria, you know, that splatter spatters spray aerosol doesn't kind of go all over the place. I want to ask, you're familiar with Isolite, do you use it? And the idea here is this, it's not just about the Isolite, it's about anything that's going to give you continuous basically continuous evacuation. Is that right?
Yeah. So I do, I don't use it on every single patient. I definitely kind of pick and choose which ones. I'm definitely for my longer procedures, like my half mouth you know, nonsurgical care. I work in a lower income and like I'm an outreach program, so a lot of my patients are migrant workers and I don't speak 100% Spanish. I speak some broken dental, Spanish. So if I have that communication issue I don't use the Isolite because I mean it does take some guidance as to like what to expect, “Here's how I'm going to size you, you know, move your tongue, whatever.” And I'm not there yet in Spanish.
So I don't do it for those patients all the time unless I do have a translator that can come in and help me if it's like for a long procedure and kind of like give them the heads up of what that they're going to have their mouth propped open for a minute.
But even then, I have the Isolite in mind because I also share my operatory on the days I'm not there with Indo and with the other docs that come in and do cosmetic stuff. So we have Isolite so there has a second hookup underneath it. I don't know what that little box is called underneath it, but there's a second one. I actually will run my second high volume to get those, that anterior portion where the aerosols are coming out. I do believe the Isolite is sucking kind of the bigger stuff down to it and some of those little guys too.
When I get to the anterior or I'm having to come up, especially like with, so I use airflow, which is a powder for biofilm management and I'm so in love with it, I will never give it up.
I'm determined to find a way to control aerosols because I'm not going back to the old school hand scale ways. When I blast from on the lingual surfaces, that's coming back out the mouth and I don't care what you got on the back there, I'm going to get some but I'm going to miss a lot. So I hold the extra high volume on the facial aspect to catch as much as that as I can.
You know, I also use something that's a bracelet. I actually think I brought it home with me, but it's called Cord Ease and it holds my high volume in here. It takes the drag off of my wrist as well. I enjoy Isolite because I'm not drowning my patients because that's my problem.
And I know that this is a level of concern with a lot of hygienists is that it's the pooling in the back of the mouth and the aerosols. It's like they're either drowning or you're throwing aerosols into the world. This is the dichotomy of seeing patients, like how do you handle this one or this one or that one. So you have to use two devices right now. In my opinion, I don't have that perfect solution and don't think you have that perfect solution for every single patient and it's going to be different and very procedural based and also patient tolerance of certain products.
So you just kind of have to go back and forth. I do occasionally use my low volume with a high volume, but with that, you need to make sure you have good backflow preventers on your low volume so they don't suck the spit back out because if you were to go across and that gravity in that section kind of came back in there and I mean it's 1 out of 5 is the number I'm learning. 1 out of 5 people get back the grossness from that suction back into their mouth, which makes me want to vomit.
I believe 100% and backflow preventers but I think it's more about with the procedure that you're doing and the patient's tolerance and your capabilities. I'm a big fan of the Isolite for that reason because it takes the drowning patient out of the game.
Communication Proper Infection Control Protocols
Yeah. And we've recently learned too that because it is constantly evacuating it can definitely help. I love the idea of including, a lot of times people say, “I don't need”, but including the HVE in their with it to maximize anything that's being thrown up, which is just huge. Yeah, that's huge. So from a from a patient perspective, what message, you know, because what's going to happen, is this with what's going on, you know, are patients going to feel fearful of going back into the practice?
It's already hard enough and I have to confess for patients to come back for their procedures. What message would you give them regarding, “Hey, here's what you need to understand and here's the the information that you need to know”.
You know, I think we as a dental profession really need to up our game and communication especially with our patients. I feel like we have definitely always approached our care as “I'm the clinician, I'm the expert and this is what we're doing. These are the things that I'm doing to you. Just like open up and let's get it done. You put yourself here.” We've kind of come at it from this from an “I am the expert” and I think we just need to have these common very open, transparent conversations.
Listen to the patient's concerns without like giving advice right there at the moment. Like if they're like, “Oh yeah, I'm afraid of the Coronavirus.” Okay, what part are you concerned about getting? Is it because I'm doing these procedures? Is it because you thought the patient before you had it? Find out what it is so you could have a conversation versus just kind of like, these are the things that we're doing.
And they didn't even ask for 90% of what you just gave them. So have a very open, transparent, open ended conversation with them and get their feedback, understand their fears, understand their concerns and you know, if this is something that you're changing, I think you should have that conversation with them.
So, “Hey guys, you're going to notice some different procedures in our practice. Just a heads up, we are here to answer any of your questions. We are always on the edge of research. We always want to include new engineering controls that keep you safe and our team safe. So these are the whys behind the things that you're about to see as you come back to our clinic and start getting these very important procedures and dental maintenance and preventive measures done at your dental office.”
I think it's super important to have those conversations like and address them and acknowledge them and really knowing your patients and who they are and like what they want to hear. There's one thing that I'm learning right now and trying to really get delve into is disc profile and knowing are they people that need like hard facts, science, like they don't like change and they need 100 reasons or are they just like, all right, you're on it. That's great. All right. Like you gave me like X, Y and Z. Your “why” makes sense to me. I'm there. Like I don't really ask a lot of questions less your “why” just seems a little weird.
Know who your patient is and you know, what their concerns are and just it's all about communication I think especially going forward and establishing that dentistry is important. It's super important. But right now these procedures that aren't emergency are being put on the backburner and when it's time for us to open back up, you might notice some different protocols and procedures and things that we might ask you to do. Like rinsing your mouth out for a full 30 seconds before you sit down in the chair. Here is why. And we're happy to expand on that if you have questions.
That is great. Really appreciate that. Holy cow. So when you look at this space, you have been a passionate champion for a long time and I would encourage anyone who's listening right now, there are quite a few articles that you've written. I've read them and I'm blown away by how much information and how much research you put into there. So really excited about that.
I think one of the things you cover in your podcasts is that you are a dental champion, not just hygiene because I discovered that in your hundreds of podcasts you're covering so many different aspects of dentistry and what's involved. And I would encourage people to look at that too. What, what final words would you like to give our listeners and the rest of the folks who are going to be watching this? To close this out. What would you want to tell them?
You know, where I’m at today and I feel like it changes every day, I feel like I keep reading people, hygienists, dental practitioners a little afraid of going back and like, “Oh my gosh, should I just go back to hand scaling?” I would be very cautious about slingshotting backwards too far. I think it's totally reasonable to be a little uncomfortable going back and thinking about things like, “Am I going to get sick? Am I going to bring it home to my family?” Totally reasonable fears at the moment, but I think you have to work through them and really kind of walk into your practice with fresh eyes. Just reassess your protocols, your procedures.
This is a fantastic time to really rethink your standard operating procedures, infection control, and aerosol management. I think that you're going to want to lean into the comfort zone of, “I'm just going to hand scale it. I'm going to do very little stuff.” That's actually not the best thing in terms of standard of care. What we were really learning was hand scaling is not the end all be all. It's biofilm, it's biofilm management and that creates a lot of aerosols. It's about using the engineering controls that have been established already in your practice to keep you safe and just remember that you are an amazing dental professional that can train through the awkwardness.
We started not knowing how to put our hands in mouth now you could probably do it while you sleep and so just remember anything that is bringing going to be new after all of this, you can train through it, you can become good at it. It's going to be so awkward and horrible at first and you're very normal pattern, routine little world is going to be kind of torn apart for a minute but you can do it. You got this. Don't worry. Just think rationally and just come into the op with new, fresh eyes in ways that you can make and better changes for the safety of you, your team, and your patients.
Awesome. Thank you. Thank you so much for that. And thank you for taking the time to speak with us. I look forward to seeing more of the things that you do and watching your, your live videos and your podcasts articles and all. And yeah, really very much appreciate it. Thank you for taking the time with us and please stay safe and it was a pleasure.
No, thank you guys for bringing me on. I love it. Thanks for having a, a place for us to chat. Awesome. Thank you. Alright.