Mitigating Health Hazard Risk in Dental Practices





By Lexi Marino September 21, 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. Brian Baliwas, DDS to understand the analogy behind a “layered approach” in terms of PPE, safety protocols, and engineering controls directly relating to COVID-19.  

Watch this video to learn the following:

  • Why we need engineering controls in addition to PPE
  • Taking risks in your practice by adopting new technology
  • The importance of social media and dentistry
  • Having mentors and connections with people you trust to give good advice
  • Using intraoral high-volume evacuation and its relation to negative pressure

Dr. Brian Baliwas, DDS:

I’m here with a bowl of M and M’s because I had to work through lunch.

Rolando Mia:

So, you’re going to have a sugar high and then you’re going to crash.

Dr. Brian Baliwas, DDS:

M&Ms are like the lifeblood of our practice.

Rolando Mia:

Right on. So first of all, thank you for joining us. Welcome to Dental Voice, Season 2. Today we get to talk to Dr. Brian Baliwas, DDS who I am personally really excited to speak to. The reason is we know each other is when we met each other, like a bazillion years ago, right?

Dr. Brian Baliwas, DDS:

Yeah. I remember that. That was in Chicago Midwinter.

Rolando Mia:

We were in line and you were so excited about social media and dentistry and we’re like, “What’s this guy talking about?” You remember that? Look at you now! I love it.

So, take us through that. How are you doing and how are things?

Dr. Brian Baliwas, DDS:

I mean, I think they have been good. You know, it’s interesting. We, we all ask each other, “Hey, how are you doing? How are you holding up?” And when we reply, “Good”, or “I’m doing fine”, it starts to transition us towards like this new, what I say “normal”.

We’re adjusting. We’ve got PPE in the office; we’ve got protocols in place. Most importantly, we have staff who feel safe. Also, just as important, we have patients who feel safe, so things have been good. We were just kind of cruising along, trying to navigate our way through all of this.

Rolando Mia:

It’s amazing to think that in the span of several months everything, as we know it, is completely thrown on its ear and we’re having to change. Literally, every day we’re learning all sorts of new things. How do you personally separate what you’re hearing versus what you’re actually implementing in your practice?

Dr. Brian Baliwas, DDS:

You know, what’s interesting is, I would say that we’re at a point right now where if somebody told you, we’re only doing what the science says, I’d say that that person has no idea what they’re talking about. I still think we’re in this position right now where we’re doing the most we can because we don’t know, you know what I mean? Like right now, even you take something like a mask, everybody’s like, “Well, I want to wear a N95.” We’ve been wearing surgical masks for decades and those surgical masks, not everybody was even wearing Level 3’s, right? There were some offices who, this was the catalyst for them, and they said, “there’s different types of masks? Correct.

What’s interesting is, you know, there were airborne diseases like tuberculosis, right? These were aerosolized and whatnot. My thing is right now, we’re all doing what we can. When we do something, it’s either to make ourselves feel better or it’s kind of overkill to make sure that we have our bases covered, or we do find some science that says, you know what, I think that may connect to this. Or I think this covers this, you know? However, I believe we’re still in this, we’re doing more. Or at least we’re urging people to do more than we actually know.

Rolando Mia:

That’s what I think what makes people feel so apprehensive because now we’re operating on what we “think” vs. what we do know. You don’t seem to be even the slightest bit funky about that. How come?

Dr. Brian Baliwas, DDS:

It’s interesting. Without getting too political but we’re American, right? It’s funny, you hear this on the news, you see people who are like, “I have the freedom to do what I want”, but there’s this like gray area of look like, yes, I personally believe it’s everybody’s right to not have to wear a mask if they don’t want to. Same goes for if you don’t want to wear a seatbelt, believe it or not, and this will cause some controversy, but I don’t think it should be forced upon you. However, you’re going to suffer the consequences, right? The interesting thing about masks per se is it’s not for yourself, it’s for other people and what is it to you? So, it’s this little gray area of the true inconvenience oof doing that kind of stuff. That connects to dentistry where, you know, a new product might come out you know, a new procedure, a new protocol and we’ve got to say that even if that science isn’t there, what’s the cost, right? If it’s not a lot, and it’s not that much effort to implement, I’m on the, let’s do it until we know more. Right? I’m to fall on the right side of things. So that way, if something bad were to happen, I’m not saying, “Man, I wish we did this.” Do you know what I mean? I’d rather say, in the future, “Hey, by the way that wasn’t doing anything but at least I cared enough to do it.”

Rolando Mia:

You know what, what I hear with what you’re saying? And it resonates very strongly with me. It’s better to do something than to just sit there and do nothing. When you do nothing, you basically have done nothing.

Dr. Brian Baliwas, DDS:

Exactly, exactly. You know, it’s funny, like if we were standing in the middle of the street and somebody came running down the street and they were like, “Run, there’s a dinosaur headed our way!”, I’d look at you and I’d go, “What the heck is that person talking about?”. Now, if another person did it and then another person, I might look at you go, “You know what? Let’s just run.” We might come to the end of the block and look back and go, “Well, that was stupid.” So, it was a prank or whatever, but the cost benefit there of us not running and getting eaten by a dinosaur, I just don’t want to take that risk. Does that make sense?

Rolando Mia:

Yeah. I mean, one or two people saying, “There’s a dinosaur.”, you’re like, “You know what? I don’t want to test this – I’m outta here.”

So, check this out. The big issue that we have is that there’s so much talk about so many things that people aren’t quite sure what things to deal with. And unlike the metaphor you just said, it’s not just one person or a hundred people, each of them is saying something different. One thing that is consistent are aerosols, right? Even lately, we’re seeing that aerosols potentially cam have the ability to carry airborne viruses, bad things. I’m just going to call it that viruses, bacteria, right? Tuberculosis, whatever. Now, negative pressure rooms have been the standard in hospitals forever. Now, there’s a lot of talk about it in dentistry. What are your thoughts about this whole issue of negative pressure rooms?

Dr. Brian Baliwas, DDS:

You know, it’s interesting. I’m one of these people that says, “Aerosols have been around for a while.” It’s not like all of a sudden aerosols have been created because of COVID-19, you know? Aerosols are here and we’ve been dealing with them. Again, I think that it’s a wide range of things. When we consider what dentists do for safety, it isn’t one end of the spectrum of doing nothing and it isn’t the other side of the spectrum where we’re doing everything and it isn’t so much, here’s what we should be doing. There are a wide range of different types of practices and people and how they operate. I think what we’re trying to operate within the bell curve of where things should be. So that being said, I think that, you know, again, I’m trying not to offend anyone but COVID-19 happens and I was getting a lot of people going, “Hey, are you wiping everything down in the room? Are you like clearing off your countertops?” I’m like, “You know, if you had asked me that last year, my answer would be, yes. It’s not just because of COVID-19.” There are other aerosolized diseases, we should find out what our standard is, universally. That’s why it used to be called universal precautions. Right? Let’s protect from everything and then make that our baseline. Then, if there’s specifics, we should go from there. And so when you say, “Oh, you know, these negative pressure rooms”, that’s where I’d like to find out the science. I’d like to know what the trends are and has COVID-19 been spread through a dental office?

Even though those aerosols exist, the other thing that exists in our office is PPE. So, a lot of people were saying, “Oh man, dentists are high risk as they’re in close proximity, you guys generate aerosols. You guys see a lot of people.” And I go, “Yeah, but are we doing things like analyzing risk.” Analyzing risk is always a Seesaw. There are factors that cause it and factors that protect you against it. So, where are we on that Seesaw? I would say that in practices that were really following proper PPE and have had good sterilization disinfection protocols in the past, this change of how much we have to do now, isn’t that big of a deal. Does that make sense? It’s like, we’ve had to do some extra things. Whereas for some practices, it’s the end of the world. They say, “I’ve got to do what!? I’ve got to wear a mask and I’ve got to do this?” So, I don’t think there’s a specific answer if that makes any sense. We try to do what’s best and where did we lie in that range of protecting ourselves? Does that make sense?

Rolando Mia:

It’s a function of what you believe and what you’re willing to put your energy in. I like the reference you made, which is, you know, dentistry has had PPE and infection control. You can kind of see the people who’ve been doing this on a regular basis and now they’re just doing more. But then other people go, “Wait a minute, we have to wipe everything down?” It kind of makes you think, about those people, “Wait, you didn’t do this before?” So, that context is there.

When I met you, you were talking about social media. How do you see that affecting the ability to communicate all these things that you’re talking in relation to COVID-19?

Dr. Brian Baliwas, DDS:

You know what, I think it has a huge effect, not just on COVID, but just how we practice in general. I would say it’s good and it’s bad and it’s good. And it’s bad for the same reasons, which is information passes super quickly, just like this. You know what I mean? Like tomorrow anyone with a platform could post anything they want and that can either be accepted or declined, or it could just morph into anything you want.

So, if it’s something good and science-based awesome. If it’s not, you know, if you wanted to, I don’t know, hold a place in the government and start a Twitter page, that information just gets passed on. Again, these days with social media, I think I talked to you about this a little bit. There’s, you know, cancel culture and call out culture. People don’t think. They don’t see a post and say, “Let me research this and think about it before I repost it or react.” When people see a post, they react, they go like and comment. They say, “I need to share. I need to agree. I need to disagree. I need to put my foot down and I have to call in the troops and make sure there’s other people who think just like me.” So that being said, it’s good and it’s bad. I think social media plays a huge role in this. I also think social media is actually in its early stages cause it’s still evolving, and I think we need to find the ethics of it. If that makes any sense. You know, there was a time in the past where cocaine was put into soda and it was used as a drug to numb people. Then we kind of figured out from an ethics standpoint and from a use and what this is turning into, we should probably throttle that a little bit and not do that. Right? Social media is kind of the same way we’re in these early stages that people are using it to do all sorts of stuff.

I mean, I’ve used it to build a practice. Companies use it to sell products, dentists use it to promote themselves. However, pretty soon we’ve got to start figuring out what’s right. What’s wrong. What’s not allowed.

Rolando Mia:

It’s such a good point too, because you’re right. There is little validation that occurs because of the speed and the fact that you want to jump onto things quick. It’s almost gotten to the point where you see something and people are responding and because of that you think, “Oh, that must be real.”

I liked the way you think. There’s a proactiveness around the way you think because you’re looking at this from a bunch of different directions.

Dr. Brian Baliwas, DDS:

Another great analogy for what’s going on now is what happened with the AIDS epidemic. I wasn’t around for that or I wasn’t a dentist back then, but I’ve heard stories about what went on. So, if you look at how that sparked a new era of dentist who were using gloves and masks and protecting ourselves. Right? What was interesting is after the AIDS epidemic, cease from being an epidemic, doctors and dentists didn’t all of a sudden say, “Oh, well, thank God. That’s over. Let me take off my gloves and let me go back to where I started.” So, we learned from that, we improved our protocols, and what we do to protect ourselves, our patients, our staff. So, instead of being so focused on COVID-19 specifically, you know, there’s people who were like, “Oh, well, you’re wearing a mask. You know, COVID-19 particles are this big and they can shoot through there”, and “Oh, did you know that it’s aerosolized? Oh, did you know, it’s found in droplets?” Again, we need to take a step back and go, “What are we doing as a profession to protect ourselves or patients and our staffs from everything?” Right? Not just COVID, but also from what could happen in the future and where the provocative piece you’re talking about comes in.

It’s so easy to fall in the trap of like, this is what’s going on in the news or this is the hip thing. We just need to think a little bit, do you know what I mean? Cause there’s a lot of emotion out there.

Rolando Mia:

When you think about emotions, emotions are very visceral, and they just come out. What are you currently doing in your practice beyond PPE to be safe?

Dr. Brian Baliwas, DDS:

That’s a good little analogy there. There’s this idea of there’s this pyramid that talks about mitigating risk in your practice and at the top of this pyramid is actually eliminating risk. So, the best thing you can do is right now, if you could snap your fingers and get rid of COVID, then congrats. That’s the best thing. No one can do that right now. There are layers, so you start getting into, look, if you can’t get rid of it, can you separate yourself from it? Right. Hence social distancing, that kind of thing, screening patients. Right. Kind of trying to get risk factors. And as you get lower, lower in the pyramid, the percentage of how accurate that helpful that is goes down. Right? So, you know, getting rid of it, awesome screening patients and asking them questions? Well, you know, some people slipped through the cracks. Right?

Some people are asymptomatic but as you go down, all of a sudden you start going, “Okay, what can we control at the end office level? What about our staff? Can we practice a certain way? Can we keep things routine? Can we start doing rinses pre rinses?” We’ve been doing this. I used to do that before I placed implants and it kind of makes sense that we should clean somebody’s mouth before we start aerosolizing whatever’s in there. Right? Even if they didn’t have COVID, if they just had a cold again, sounds kind of like a good idea to kind of sterilize their mouth before I kick stuff up in the air.

Then as you go along at the very bottom of this pyramid is PPE. So, what’s interesting is everybody is so concerned about the PPE, but it really does the least amount for us. It’s kind of like the last line of defense. So, our big focus isn’t so much on our PPE, but for our patients, we do have N95 face masks and face shields. We use reusable masks. We have a washing machine at the office, luckily. So, we’re doing all of that.

As we kind of climb up the pyramid, we’re really focused on what can we do to mitigate our exposure and risk. So, we try to limit how many patients are in the room or in the office. We’re screening patients, even if somebody says, “Oh, I just took a trip to Mexico.” We say, “That’s awesome. Let’s just see you in two weeks.” It’s not a big deal. Chances are, if we roll those dice, nothing’s going to happen.

Is there a chance that something could happen? Yes. Again, risk reward. If something happens, what happens? We shut down. I have to contact all the patients who were in that day and beyond and say, “Hey, by the way, there’s a chance that now I’m doing tracing.” I don’t want to be the first to be on the news, do you know what I mean? Local dentist in San Francisco, a super sprinter office, like no thanks. So that’s, so when we weigh the risk reward, I would rather just wait. Right? Also, I’m fortunate to have a patient base that is honest with me.

You know, I’m not churning through patients. I’m not seeing 30 patients in a day. These are people who I have relationships with, who understand the protocols, who don’t give us a hard time when we’re taking a pulse oxs or a temperature, or we’re asking them to wear their mask before we walk them up. We just don’t need that. If somebody is going to give us a hard time, they’re gone. So that’s our focus, making sure that where keeping people safe, keeping the staff safe. Then also making sure that the staff, the other doctors, hygienists are being responsible. You know, I’m not hosting COVID parties at my place. I’m not eating it busy restaurants. Right? Yeah. And again, that’s not a hundred percent, there is a chance knock on wood that I can just be walking down the street and the wrong gust of wind happens to carry enough COVID-19 particles and I get infected.

It’s all a numbers game. You know what I mean?

Rolando Mia:

So, are there systems that you have in place in your office to try to minimize that aerosols or any of that type of stuff?

Dr. Brian Baliwas, DDS:

Yeah. You know, so this is where we start getting into, does it work right? I’ve always been a big rubber dam person. We talked about this, that before Zyris was Zyris, it was Isodry or Isolite Systems and actually when I was a student, my second year I won a competition at the school, like a clinical excellence day. I think it was for dentistry and I won an Isodry and I remember introducing it to the office when I first got hired. We’ve been practicing with them ever since. So that’s one way to reduce aerosols. But you know, Kois says, brought up that even just having the HVE right over what you’re aerosolizing when you’re using a handpiece, like Cavitron, it produces a ton of aerosols. Right? So, do we have to do those procedures? Can we hand scale if we can, can we avoid polishing? Although again, from a polishing standpoint, in my mind, that’s droplet and not aerosol. I mean, I’m sure it aerosolizes a little bit, but really what you’re doing is flicking little pieces of prophy paste everywhere. So that’s a little controversial, I’ll probably get some DM’s from hygienists right now. We try to minimize aerosolization with high speed handpieces, we try to open the windows when we can, and then we have a lot of air filters.

Again, a lot of people will say, well, COVID is so small. It’s about moving air, not letting things be stagnant with any kind of disease, bacterial or viral. It’s all about the load and time, right? Like how much of the virus is around and how long are you exposed to it? If you can kind of move that stuff around, we’re doing what we can. What else do we note at the office? Sneeze guards up front, you know, just the typical stuff, I would love this’ll never happen, but I’d love to see a study somehow that says like, do the sneeze guards when you check out protect anything, you know? And I don’t know. I would think that if somebody were to sneeze, then yes. But just being there, I’m curious how that works.

Rolando Mia:

First of all, I do remember when you won that system and we’ve been told by other clinicians who mentioned something about how it creates a negative pressure area inside the mouth. Do you believe that? Or what are your thoughts on that?

Dr. Brian Baliwas, DDS:

Interesting. And I’m really upset that they never got this off the ground. If you reach out to Jesse Lay and Dr.Hakeem, they were trying to do a study where they were measuring the humidity around teeth, using nothing, using a rubber dam and using Isodry/Isolite. They actually found that it was equivalent to full isolation or the rubber dam in terms of sucking up that, that air, so I guess you could say that. I think it’s doing something. I mean, it’s just physics, right? If you’re sucking something up and you can hear it sucking, what is it sucking up? It’s sucking up there. Where’s that air coming from? Well, it’s only connected to the mouth. So the only thing I can think of is if there’s different jet streams in the mouth that, that maybe it’s causing some, I don’t know, but for me it helps. Outside of COVID-19, we’re really big on isolation, just so that our dentistry lasts. Again, going back to our original point, is this your “aha” moment to use isolation? Did COVID-19 give you this “aha” moment? Or should you have been using isolation from the very start? You know what I mean?

Rolando Mia:

Good point. Really good point. You know, it’s, it’s interesting that you mentioned that when you finished from school, you went to UOP, is that correct? And you started with a group practice, is that right? From there if I understand correctly, you’ve transitioned away from groups. What was the logic behind that?

Dr. Brian Baliwas, DDS:

It’s funny. Adam Miller and I actually started our own practice and we always joke around, we are really bad employees and what I mean by that is like I want to do things my way, I want to be responsible for things, and I want to take risks. I want to fall on my sword. I want to be that guy who says, “Look, we’re going to do this. We’re going to try it. Let’s do it.” Do you know what I mean? It’s hard to do that when you don’t own the practice. No matter how much autonomy you’re given, you need that pressure of like, “Wow, these people are depending on me for jobs, there’s patients depending on me to keep this thing going.”

So, we’re bad employees and we decided to go off on our own. We bought a practice last April.

Rolando Mia:

And how’s that going?

Dr. Brian Baliwas, DDS:

It is going well. Except for those of you guys who weren’t tuned in earlier, I’m munching on M and M’s right now because I had to work through lunch. It’s busy is really busy, but it’s going well, I’m learning a ton. If you’ve seen my page, I’ve been sharing a lot of my adventure, kind of with products we bought, things we’re doing around the office, and things we’re learning. This is a learning opportunity and I’ll just continue to share what I learned with whoever decides to follow and pay attention.

Rolando Mia:

I love the sentiment, another the message behind that move forward and execute, do something. If you don’t do anything, you don’t learn anything. Once you’ve started learning, then you adapt and you move forward from there. That’s basically what you’re saying, right?

Dr. Brian Baliwas, DDS:

Yeah. I mean, there’s always limitations to things, right? Like Zyris could come up with a new device that might decrease humidity and whatever aerosols by X percentage, but it costs $30,000. Right? So like there’s always like a give and take. And so you can’t be the person who’s doing everything, but you’ve got to be smart. That’s the problem solving that comes with owning a practice. You have to ask yourself, “Where do we divert our attention? Where do we divert our finances? What is worth it? What’s worth exploring and when do we pull the cord?”

Rolando Mia:

There are practices that are not going to be opening after this. Here you are. You’ve gone out on your own and you’re successful. You’re busy. What advice would you give those folks who are still struggling, may not even have opened up, or if they’re not clear about what to do? What advice would you give folks?

Dr. Brian Baliwas, DDS:

If you’re struggling right now, you had three months of patients as a backlog of people who need to get in, you should be busy right now. Right? So if you’re not busy right now you’ve got to work on your recall systems. You’ve got to work on maybe implementing some sort of software that gets patients in the door or you need to work on making your patients feel comfortable coming in.

Also, you have to feel comfortable coming in. So, do you believe in your protocols, do you believe it’s safe? If you don’t, then reach out to some people who are open and busy and say, “Hey, how do you feel? Do you feel safe? Do you, does your staff feel safe? What are you doing to feel safe?” Because again, right now patients should be coming in the door. I mean, we have it right now where if a patient cancels, that’s okay. We understand because we have a long list of people who need to come in and we’ll fill it just like that. Where it becomes scary is once we get past this backlog. So, dentistry always kind of takes a little hit a little later in a recession or a stoppage or something. As the months go on it might not feel that way as we approach November, December, because everybody always likes to get in with their benefits.

It’ll be interesting after that, come the January, February, March how busy we are, especially if this continues on. So, I would say right now my big advice, and this is something Adam and I are doing, we’re saving money. We’re really trying to budget. We’re trying to break down our budget, understand our P and L. So, as a new practice owner I’ll be honest, six months ago, if you gave me a P and L I go, cool. Is that good? Is that never good? And over being big, is that negative or positive? Like we need to know where money’s going. Then we’re kind of trying to build a little nest egg. It’s harder for new practices. It kills me.

I’ve heard of a couple colleagues who reached out and they’re like, “Man, this really hit me hard.” I’m like, “You’ve been in business for 20 plus years, right? How do you not have a little savings?” You know? Even if it’s your personal savings that you have to kick back into the practice, like you should have something. This has really taught us about budgeting. An I hope I’m wrong. I hope that there is no slow down, but my prediction is that there might be in the future, especially once we start getting caught up with things. So that’s my whole thing is we feel comfortable right now, but let’s give it some time.

Rolando Mia:

I love the forethought that you have with that. The perspective is, “Hey, now that it’s really busy, let’s be smart. Let’s be intelligent about what we’re getting here and let’s not just go crazy.” If you were to wrap this up and give message to your viewers, to the people who are following you, what would you say about the future of dentistry?

Dr. Brian Baliwas, DDS:

Future’s not clear right now, but I think we’ve been all blessed to work in a really awesome field and it’s not a field that’s going to go away. Even during a complete shutdown, I live in the People’s Republic of San Francisco, which is the most am I allowed to say, am I allowed to say this the most insert the word, you know, that I want to say right here, place in the world. I we’re putting up restrictions and regulations. Through all that, we still had people, patients, and unfortunately, they were in pain or breaking teeth and what do you do? You can’t send that person to the hospital. You could and then what they, they get their tooth pulled. There’s always going to be some sort of need.

So even during the shutdown, Adam and I were in here, we’re not too proud to assist each other and that’s what we did. We kind of buckled up and said, “Look, let’s get this done.” Even though things might get worse, who knows, there’s always going to be a need. I think that we’ve just got to stick together and share resources. Again, we talked about this earlier with social media. We just have to think a little bit, I mean, it’s so easy to post or hear something and then all of a sudden freak out or get angry and have a reaction. To tell you the truth, I am pointing the finger at myself. A year ago, two years ago, I was that guy, like I disagreed with somebody.

I was like, “Oh my God, I can’t believe they posted that.” And then I’d have to post and you know what? Life’s too short. Like you’re never going to agree with everyone. So, it is what it is. I think the more of us that kind of keep a level head and take a step back and go, “What’s really going on here?” I really believe in social media. I told you that years ago. I think it’s the future, but I really don’t like the direction it’s headed, where it’s becoming a tool to kind of rally the mob.

Rolando Mia:

That is cool. Thank you for that. For those of you joining us, this is Dental Voice Season 2. We just sat down with Dr. Brian Baliwas an incredible person and I’m so happy that we met.

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