Face Masks: What the Level is Going On?

In this society where anybody can get sued at any time, and there's a lot of employees suing employers and employees reporting to OSHA and saying that things aren't done correctly, I would rather put myself out of that concern and just go with a level three mask. Welcome to the Phil Klein Dental Podcast. So the reality is not all face masks are created equal. And understanding the risks of using subpar face masks is vital for both safety and liability. In a dental practice where high aerosol procedures are routine, inferior masks not only put your staff and patients at risk of exposure to harmful particles, but also open your practice to serious legal consequences. According to our guest today, Dr. Sheri Doniger, to protect against these risks, ASTM Level 3 face masks should be the standard of care in every dental office. These masks provide the level of protection necessary for high aerosol procedures, such as drilling and ultrasonic cleaning, ensuring both patient and staff safety. Dr. Doniger will cover a myriad of issues today related to the dental face mask, including what to look for in a quality mask, and how to train staff on proper mask practices to maintain compliance and safety. Dr. Doniger, it's a pleasure to have you on the show. It's a pleasure to be here, Phil. I really appreciate your inviting me. Yes. Yeah, we're very happy to have you. You certainly know a lot about infection control. So it's no secret that since March... 2020 we are essentially practicing in a new era of dental medicine i think all of us who work in the dental operatory are more aware of the real dangers of aerosolized particles and body fluid in the form of splatter blood and saliva and so forth, we know that that can carry infectious disease. And I think all of us as healthcare professionals understand the need for an infection control strategy for the practice, which includes quality PPE products and donning techniques, because not everybody in the office handles the PPE and wears them properly. So there has to be some consistency there. So in light of all this, what is different now, in your opinion, Dr. Doniger? in our dental practices regarding PPE, specifically with face masks? In other words, what should we be doing differently with face masks in contrast to pre-COVID with the goal of keeping ourselves and our patients safe? Well, that's a great question. Although the official COVID pandemic has ended, the risk of getting COVID and other seasonal influenza still exists. I can't tell you how many patients I have coming back from vacations that are canceling appointments because they have COVID again or a different version of it or some influenza. We're still mandated by the ADA. the cdc and osha to follow guidelines that are standards of care that include masks gloves eye protection protective clothing nothing has really changed on that regarding masks i am still at level three i think everybody should still be at level three protection i think it's something that we should uh that is a standard of care and practices was discussed um during covid and i think it's it's continuing on into our practice lives now and for the foreseeable future. So anybody who's participating in the dental operatory during a procedure in whatever capacity should be wearing an ASTM level three mask. Right. They should. Well, let me just give you a brief synopsis of why. Masks are rated with four qualities. Fluid resistance, which is the mask's ability to prevent fluid from passing through the material. The higher fluid resistance, the better protection. So you're looking for something about 160 millimeters of mercury. Then BFE or bacterial filtration efficiency is the mask's ability to prevent bacteria from traveling through the material. That's measured at 0.3 microns, and the higher BFE is better protection. So we're always looking for something greater than or equal to 98%. The particulate filtration efficiency is the mask's ability to prevent submicron particles from traveling through the masks. And those are measured at 0.1 microns. And again, the higher number is better, which is greater than 98%. The delta P, which is the differential pressure, and this is kind of an interesting number, it's the clinician's ability to breathe while wearing the mask. And that's measured in H2O per CM. wear and the higher number the better you're usually looking for something over five you want to be able to breathe if you if those folds those pleats and the masks aren't expandable to your face you're going to feel like you're suffocating all day and that's the last thing you want to do because you want to encourage people to wear masks for protection for protecting themselves and their patients and then you know everybody else that's in the office and you want to be able to have this really great delta differential and the masks. I look for all these factors in deciding how to choose a mask. And I might add, Dr. Doniger, which I find interesting, is that some of the major companies that are making masks, like Cranberry, for instance, have eliminated the level two ASTM mask completely from their product line. Let me explain to you what the level two masks are. The masks are... by the light fluid barrier is considered a level one, and that would have a fluid resistance of 80. The moderate fluid barrier has the ASTM level of two, which is 120. And the level mass that I use is a level three. and that's 160 millimeters of mercury and that is the best fluid resistance and that's what we should be using because we don't want to have we just don't want the masks wet having things passing through them so again going back to cranberry they have totally eliminated the level two mask and are only focusing on the highest level of protection this is a really good place to start when you're looking for a mask And you mentioned breathability, and that's a very, very important factor in a mask. If you can't be comfortable with the amount of oxygen that you're taking in while you have this mask on, you're going to be pulling that mask down over your chin or lifting it up on top of your head. And that's like the worst behavior you can do when you have a mask because obviously any pathogens... are on your skin, they're going to be transferred to the inside of the mask. So the user, when they put the mask back on properly, are going to be breathing in those pathogens from the inside of the mask. And that's not what we want to accomplish when we wear a mask. So comfort, breathability, super important factors when choosing a mask. And also I'd like to point out that the difference between a level two ASTM and a level three is not that critical to the point where you would even have a level two. because the major difference is in the fluid penetration and you get better resistance from fluids with a level three. And that's measured in, as you mentioned, millimeters of mercury pressure of how much pressure is needed to get that fluid to go through the fabric of the mask. It certainly seems to me that it makes more sense to consolidate to a level three ASTM for the whole practice. You're getting better protection and you're simplifying your inventory. Exactly. Prepare for, you know, the safest dental visit that you can have. And I agree with that. And I also agree, I kind of chuckle, you know, you go into the grocery store and you still see people wearing their masks incorrectly, and that's not how we're supposed to do it. of how the masks are supposed to be is right on. You want people to be comfortable wearing them. You want them to be placed on their face, covering their nose or mouth, you know, underneath their chin correctly. And you don't want anybody touching the outside of the mouth because that is cross -contamination. You've already contaminated everything. Your gloves, you have to wash your hands and start all over. You know, I've had this discussion before, Dr. Doniger, with practice owners and they say, well, my front desk, they could use a level one. Some of the people that are just doing sterilization. They might be using a level one or level two. What's your response to that when an office says it's kind of overkill having level three for everybody? We never know who's coming into the office, first of all. And when you have the front desk, somebody coming into reception and they're coughing and everything, you just don't know. So if my team is masked, my team is going to be masked in level three. Also, when somebody is sterilizing, there's always a risk of splatter. So my concern would be why risk somebody in a mask that doesn't have the correct amount of fluid protection, the highest level of fluid protection, if you are going to have any splatter in the sterilization room. So it's also easier when you're talking about cost. It's also easier when you're buying for the office. You don't have to buy three or four different types of masks. So as dental practice owners, we're all faced with higher costs across the board. I mean, everything costs more these days and it's difficult, you know, to keep your costs down. And sometimes dental practice owners look for off-brand products and that sometimes moves into the PPE world. So what is your recommendation, Dr. Doniger, when it comes to purchasing off-brand PPEs, especially in the mask area? My responsibility as a practice owner is to protect both my patients and my entire team. And we should always be really diligent to look for these great qualities in a mask, you know, to ensure that they're ASTM rated correctly and labeled. We need to make sure that. We are purchasing something that has quality backing behind it and testing. When we buy anything that's off market, the labels may not be clear. As we were warned during the pandemic, you know, always be wary of masks that have incorrect labels or words that are misspelled. I personally look for a proven quality rather than saving a few dollars. It isn't worth the lawsuit. So it seems to me, Dr. Doniger, face masks is not the air. All I think about is my role is protecting my team and my patients and my community. And I don't want to risk the protection level. I would go with a known company. Cranberry is very well known. If it says level three, it's level three. They used quality materials. Their masks aren't going to break. There's certain things you take into consideration. It's just so much easier to buy something right. and good in the beginning and use that product that the whole team is comfortable wearing and is happy with than trying to go scramble around looking for to save a few dollars i mean that's protection is not a place where i would say what i would look to save money it's just not i know the cranberry line has a mask called carbon black is there anything particularly interesting about that that you want to share um i think that the the breathing volume in there is incredible and uh i think that that's one of the again one of the things that i look at because the last thing you want to be doing is you know you're focused on a procedure you want to be comfortable when you're doing you know breathing and sitting and everything else um i think that their uh their nose strap and their um chin strap you can tightly seal around your mouth which again is in face which is again is a big factor um they have superior fluid from from all the tests i've read they really have superior fluid resistance and the ear loops are really soft and you know these things are around your your your ear for a good part of an hour you want to make sure that you're wearing something that's comfortable um and they also think one of the other things that we all you know learned during the pandemic is how the masks some of them were fogging up our glasses and these masks do not fog they're great and even if you're wearing them under a shield and a lot of a lot of practices are still using their shields if you're wearing them underneath the shield you could still breathe it's it's they're comfortable and um And there's no fogging. So what is it about the carbon black mask that precludes the fogging? The design, the customized fit. It's just how they made it. And it was just, it was incredible how they made them. And that was, I just very, very impressed, very impressed. And we are using them in our operatory. So I'm very. happy that they're there. So Dr. Doniger, talk to us briefly about the correct way of wearing a mask. And also, what is the protocol related to changing out the mask? That's excellent question. I again, we were kind of making comment about, you know, wearing it underneath your chin or, or, you know, above your eyebrows or whatever, that's the wrong way. Masks need to be worn correctly. And one of the things that is the biggest thing about masks is they should not be worn all day. The same mask should not be worn all day. The general recommendations are to change masks after each patient or If there's an aerosol procedure, after every 20 minutes, unless the mask is visibly wet or soiled, just think about it. You're sitting in the chair and somebody has splatter all over their mask and it's red. It's not the most comfortable thing to see when you're sitting in the chair. So you definitely want to know if you have any splatter on you. Sometimes you don't see the splatter saliva is clear, but there's still bacteria over that. If that mask gets wet, it really does need to be replaced. Non-aerosol generating procedures, you can probably change the mask every hour. And those are usually exams only. Mask donning, learning how to put a mask on correctly should be part of the onboarding of new team members. People should learn how to do that. It should be gone over every so often because people tend to forget. the infection control manager should do a review for team members at least once a year to ensure that everybody understands mask hygiene. And a lot of the stuff that you and I were just talking about, a mask is only as good as it fits. It's the most important thing to consider are the adjustable nose and chin pieces to custom fit that mask to the clinician's face. They should mold over the nose and the cheeks should be covered and it should be molding underneath the chin. And they should maintain their shape during the time that you're using it. They shouldn't kink. They shouldn't break. You know, it's horrible when you've got this broken metal that's right next to your nose or underneath your chin. Individuals with wider faces should select a mask that ensures full coverage that will cover. the face and under the chin cranberry again is a leader in this they have masks for they have petite masks and they have regular size masks and i happen to need a smaller mask because my face is a little narrower it's really important to be able to get a mask that fits your face the pleats just as a reminder to everybody should always face downward. And the folds should allow for enhanced breathing volume. And that's what we were talking about with that differential, with the breathing differential. It's so important to get that Delta P to have a large, to be able to get your breathing correctly during wearing masks. The side elastics are there to basically to reduce the fogging and the gapping around the face. You asked about the comfort of the side elastics, and that's really important and that's how there isn't the fogging going on. These also should be secure and not tear away from the mask. I've had masks that we've sampled in the office that you put them on and pop. the elastic comes popping off just as you're putting it over your ear. That's not a good thing. So again, stick with a mask that's with a reputable company that you know is creating masks that are well. Again, it is important to find a mask that fits your face. They should feel they aren't going away. masks aren't going away, so they should feel comfortable when you're wearing them. Manufacturers make a variety, as they said, of sizes, and you can make sure that they're sealed so you're protecting yourself. You can ask your sales rep or contact the manufacturer directly to sample masks that'll fit your face. Finally, used or contaminated masks should be cared for as any other medical waste in the office, and following the procedures and protocols as described by the ADA, CDC, and others. throw them away the right way and only use them once. Yeah. So let me ask you something about the other employees. So you have a practice, your favorite assistant got married and moved to Missouri. So they're no longer around. You hire someone new. You start observing the way they're donning their mask, for instance, and you notice some really bad habits. Tell me what you would do. You're the owner of the practice. So would you get involved with getting that? person to change their habits so that, you know, the office is running on a system of perfection when it comes to donning masks properly? Or would you have your ICC, your infection control coordinator, do that or one of your other employees? How do you approach that person where it's not like disparaging to that person that they come in and they're just doing this really incorrectly? You want them to be positive about their first week in the office, but you also want them to be safe and you don't want patients to notice the difference in the way they're wearing their mask, maybe under their chin part of the time, in contrast to the other employees? That's a great question. I have a small practice, so I pretty much would have to explain this to the new employee. I would take them aside and discuss it with them. I would... you know, just go over, take a mask out, fresh mask out, show them what it's supposed to look like and how to discard them. I think it's in a larger practice, an infection control person or whoever's in charge of team training would be the person that would be reviewing how the new employee would be. not only donning a mask, but donning their gloves and their lab coats and all the other personal protective equipment that they'd be using. But it's kind of, there's so many infographics out there that you can show people how to wear their masks and how to be safe. And I would have a conversation again, you know. bringing it back to safety. This is to protect you. We want you working here a long time, and we want to make sure that you are as safe in this practice as possible. Now, you need a certain amount of training every year, right, for OSHA guidelines, and you also need documentation in the office. Correct. Yeah, so what you just said, is that something that should be documented so that when someone's onboarded? They look at this documentation as part of their training and sign off on it so that you have legal documentation. You have something to show an attorney, God forbid, you're sued or something, that all of this stuff was handled in the best possible way and it wasn't ignored. It's not negligence if somebody... something wrong that could lead to the transmission of a blood-borne pathogen from one employee to another or, God forbid, a patient to an employee or vice versa. Where is this documented or is it? There are employee manuals. There's also OSHA training that... have to go through yearly, minor yearly. And we also have and they do have to sign off. And we also have state mandates are different. I, you know, I can only speak to Illinois, but California might be different. There might be different ongoing things that they have to take. There has to be continuing education offered. I think that. I again, I think that it's it's definitely part of the onboarding thing. You can't expect to hire somebody and they know how to not only mix every single every single bonding agent that you have and and put a mask on and do everything the correct way because nobody knows how they were trained in their last practice. So every new employee that comes in, you have to treat them like this is their first job and that they should they should learn. the right way. So I know you're not a lawyer, Dr. Doniger, but what is the legal risk involved with a scenario where a practice buys an off -brand mask and it claims to be a level three, but obviously when, let's say, something happens and the masks are tested and they're inferior, they don't match up to the claims that were made on the box or what was made on the website where it was being sold, or The scenario where there's random masks around the office and the dental team member meant to pick up a level three mask, but because there were level one and level two masks in the practice, they picked up a level two mask and they went into an operatory where there was a very heavy aerosol and the level two mask did not have the protection against fluid penetration. And God forbid there was a transmission of a illness from the patient to the employee. It seems to me there would be quite a lot of liability. on the practice if something like that happened. So if you can, just briefly address that. In this society where anybody can get sued at any time, and there's a lot of employees suing employers and employees reporting to OSHA and saying that things aren't done correctly, I would rather put myself out of that concern. and just go with a level three mask, the highest level of protection, have absolutely the best training and make sure that everybody is protected the same way I'd be protected. You know, as a practice owner and the lead doctor, my job, as I said, is to protect not only my patients, my team, but myself and my family. As a mother and a grandmother, I want to ensure that I'm using the highest standards of masks to keep us all protected and avoid any kind of loss. Yeah, and that's a good point that you made that there's actually concern about employees suing employers and reporting them for reasons of being terminated or any reason actually. They feel that they were mistreated in some manner. They didn't get the vacation time they thought they would get and then they just send in a report and then you're vulnerable. So an office certainly doesn't want to be in that situation. So Dr. Doniger, it's been very helpful and we're really happy to have you on the show. Any closing points that you would like to make for our audience? So just to clarify, there are several companies that make great masks and Cranberry is one of them. They're just the ones we choose for our practice. You certainly have the ability to choose whatever. you would like to use in your practice. But find something that you're comfortable using and that your team likes using and stick with a level three. Thank you very much, Dr. Doniger. We appreciate your time. Thank you so much. Thank you, Phil. It was an honor. Appreciate you asking me.