Infection Control and Prevention: The Devil is in the Details; A Discussion with Emily Boge

The other important thing is the viruses. And if you're not using something that's aggressive enough to permeate their layer or their capsule on that virus, then you're not going to get viral death. And that's the really important thing. Cold and flu season, COVID, all that kind of stuff. Welcome to the Phil Klein Dental Podcast. So there are many of us listening to this podcast who day in and day out do their very best to keep the operatories in the practice in which they work. clean, and disinfected. Their goal, of course, is to maintain the CDC guidelines as best they can so that our patients are at minimal risk of contracting an infection when visiting their dentist or hygienist. Today, we'll not only cover the basics of infection control and prevention, but also its nuances. And as they say, the devil is in the details. We'll talk about spray versus wipes, single-use inventory, the use of cold sterilization. the Infection Control Coordinator, also known as the ICC, and the opportunities that lie ahead for today's dental hygienist and assistant. To share all this with us is our guest, Emily Boge. She is one of the most knowledgeable and outspoken educators you'll ever want to meet, especially on the subject of dental assisting, dental hygiene, and of course, infection prevention and control. Emily blends her extensive experience in dental hygiene and dental assisting with a dual doctorate in education and organizational leadership. We'll be getting to our guests in a second, but first, for the optimal bond between zirconia and your resin cement, check out Bisco's Z' Plus. Rated best in class by thousands of top clinicians, Z' Plus featuring MDP creates a strong, reliable bond to zirconia. metal, and alumina substrates. And nothing could be simpler. It comes in a single bottle, and it's 100% compatible with both light-cured and dual-cured resin -luting cements. It's time you get the most out of your zirconia restorations. To learn more about Z Prime Plus and the entire Bisco adhesive product line, visit bisco.com. Emily, thanks for being on our show. Well, hello. How are you? I'm very good. And yourself? You know, I can't complain today. It's a beautiful day. Good. Well, that's the way it should be every day, but it's not always a beautiful day. But inside, if we have harmony in our life, then it's a beautiful day every day, right? The rest is just weather. Yeah, the rest is just weather. So getting into the topic of this episode, Emily, we know that every dental office has to be mindful of the spread of infection, right? The transmission of bloodborne pathogens is so dangerous today. And of course, we went through the tough two years plus of COVID. that really turned things upside down in our dental practices and ultimately resulted in a pretty severe staffing crisis as many hygienists and assistants left the profession permanently and just never came back, which we're still recovering from. Let me first go over the basics and then I'm going to ask you about disinfection because that's something that has to be done. chair side, for sure, in between patients. So cleaning, when we talk about cleaning, we're talking about removing debris and organic contamination from surfaces. And I think it's fair to say that the first step of any disinfection process is cleaning, because if a surface is not cleaned, the disinfection process obviously will be compromised. And then we get into disinfection, and that eliminates Many or all disease-causing microorganisms on an object. But it does not remove bacterial spores. That's left for the third step, which we all know is called sterilization. So I'm just going over these basics just so we use the terms and everybody in our audience knows what we're talking about. And sterilization eliminates all disease-causing microorganisms, if it's done properly, as well as bacterial spores. Takes it all out. So we know that if we use that instrument surgically, There's no chance of a bloodborne pathogen being spread from one patient to another, which is very dangerous. And obviously, sterilization is done by heat, steam in our autoclaves. Unsaturated chemical vapor is also another way to sterilize. And then we have liquid chemical sterilants, which you're going to be talking about later on in this podcast, cold sterilization, which I know by talking to you before we started, you're not a big fan of. Now it's gross. Yeah, yeah. So we're going to hear from you. So now that I did... Quite a bit of talking. I want to ask you about basic disinfection, which is the middle level, which we just talked about. What are our goals when we disinfect in the operatory, when that patient leaves the chair and the new patient, we're waiting for the new patient to come in. And should we be using wipes or spray for disinfection? Well, OK, so that's that's kind of a big question. So let's unpack it. Right. First of all, I do so appreciate you going through the definitions because the words we use matter, especially at this time. The staff shortage right now, the dental team member shortage is really contributing to a lot more on the job train health care professionals in the dental setting. And so. Our first step needs to be teaching those folks who are coming. I know maybe they worked at the bank on Tuesday and on Thursday they're working at a dental office chair side and they need to know the difference between clean, disinfected and sterile because that the words matter. And so let me move on to the next stage of unpacking. So what do we use to clean things? I always think. When you're truly cleaning something, soap and water, right? Soap and water. Like my kid leaves a pile of Cheetos on the counter. I kind of gather the Cheetos up. Maybe some of that orange powder is still on the counter. I take a wet, warm cloth, whether I use some soap on it or not, and I wipe the counter off. I have cleaned the counter. Now, then you say, what if I want to disinfect the counter? That's when you let one of the EPA's plethora, of chemicals come into the equation. So if you're using, you know, in the dental setting, we're looking at an intermediate to high level disinfectant. And so then dental professionals will say to me when I lecture on infection control, well, which one is the best? And there's a list that the EPA gives of qualities that you can look for in an effective disinfectant. Some of those qualities include the tolerability of your team. They have to like it. It has to be something that's not going to get them sick. They're not going to inhale it and get headaches, stuff like that. It has to have a fast, what I call kill time. The people who are a little less direct like to call it effectiveness wait time. So how long is it going to have to sit on the surface to truly disinfect the surface? And then you have to look at that in terms of your workflow. Maybe you're a really busy office and you can't wait three full minutes. So you want to choose something where you only have to wait one minute to get that same intermediate effectiveness wait time. And so the EPA has come out with this list that they say, you know, hey, dental professionals, we really want you to use something off the N list. So if you're listening to this podcast and you want to make sure what you're using is correct. Go ahead and Google EPA endless disinfectants. It's going to list a whole bunch of different things. And then you can look at those and say, okay, am I in a really busy practice where I need something that I only want to wait a minute? Do I want to wait three minutes? Do I want to wait two minutes? Whatever. And so that disinfection process is the next stage. So back to those Cheetos on the counter. Maybe your kid has strep throat, right? So the kid just ate the Cheetos. You wiped it with a cloth. You rinsed your cloth out. um i wouldn't put it back in the sink it would go in the wash if my kid had strep but the next step disinfecting that tabletop so the rest of your family doesn't get sick is that disinfection process. And at home, you know, we don't really want to start using these intermediate to high level disinfects for home use because then we're going to be starting to create an antibacterial resistance strain. And so when you're at home, things like Clorox wipes. you know, Lysol disinfectant wipes. That's the kind of stuff we use at my house when people are sick, or I just wipe down stuff periodically for doorknobs and door handles to make sure people don't spread sickness in the house. But when you're in the dental setting, you really need to have one of those endless because we're at a higher level. The aerosols we're producing, the schmutz is flying around the room, all of that stuff. We need to have a responsible outlook and say, we're going to break that chain of infection every single place we can break it. And so using something off that N list becomes really, really important when you're in a situation where you're producing more aerosolized germ and microbes and stuff. When you say N list, is that E-N-D or N? N, like the letter N. Okay. So what was the web address again for the EPA? I always just Google it when I'm looking for it, but it's just EPA, Environmental Protection Agency, N. list disinfectant okay n is in n is in nancy n is in nancy like the letter n i know sometimes my midwest people tell me i have a midwest accent but i don't hear it yeah well you don't you don't usually hear your own accent but n yeah n list is is just some sort of random name they gave the list of those disinfectants that fall under the epa acceptance list Right. And it shows that it's effective in a healthcare setting that where a high level of aerosols are being produced. Right. Okay. So go back to the Cheeto metaphor, which was very good. So you're doing disinfection because just in case your son has strep. So you've basically cleaned, you remove the chips and the powder. Now you've disinfected. What do you use at home? I just use a Clorox wipe or Lysol, whatever's on sale at Target. Okay. Or Walmart, wherever. Okay, so now let's make that comparison to the dental office. What are we looking at as far as a patient gets up, they just had a full crown done, there were some gums bleeding, and the patient had a little bit of a cough that you noticed before they started the treatment, before you put the rubber dam on, the patient was coughing a little bit. Generally, you'd think the patient was healthy, got up, left the chair, now you're waiting for the next patient to come in. What kind of preparation as far as cleaning and disinfection are we looking at for the staff? Right. And that's, that's a great idea. And I love the fact that you pointed out that whether or not that patient was coughing or not, we assume everyone has the bubonic plague. And that's how I present it to students their first day of class. Like you, you, you assume everyone, if they have a fever or they're, they're actively symptomatic. And you, once you find that out, you send them home. Unless it's something where we absolutely cannot wait, but very few things in the preventive world. If they have 102 fever. or they're hacking up a lung, or they have an active viral lesion on their lip, there's very few things that we can't reschedule. And so back to the situation of assuming that everyone is sick that comes in our chair, we have to treat the post-op cleaning and disinfection sequences like they're sick. And so you don't really want to have two chemicals in the operatory where you're using one to clean and one to disinfect. And so you want to go down the road of spray, wipe, spray, If you're using a sprayed product and a piece of paper towel or wipe, discard, wipe. And I know the wipes are a bit more expensive. What I like about the wipes is it's not aerosolizing all that endless disinfectant to where the people who are working in the practice are breathing it in all day. So it might be a little more expensive to have the wipes, but ultimately. The companies are really good at making sure that the wipes stay saturated as long as the containers stay closed. And you're going to want to wipe that surface to cleanse the area, maybe a little bit of blood out of the patient's mouth, maybe some saliva, maybe a little bit of piece of the temporary crown or something. Wipe that off all of the surfaces that are contact surfaces. And then you want to get another wipe out. and you want to wipe it a second time and what that second process is doing is disinfecting and then you wait for that manufacturer's effectiveness time, what I call the kill time. How long is it going to take to kill all the bad guys that are flowing around on this countertop, right? So at what point is that product truly effective? Three minutes, you wait three minutes and you move forward. Now, during COVID, there was a lot of discussion, you know, does SARS-CoV-2 hang in the air for 15 minutes? Does it hang in the air for 20 minutes? Does it live, you know, how long does it live on cardboard versus... plastic versus whatever. At this point, what we know is if you're heating an air system, your HVAC system is doing its job. If you're getting your quarterly tests done on your suction equipment, your vacuum system, if you're making sure all of your other systems are in place, spray wipe, spray, or discard wipe with the effectiveness time is going to be adequate. So let me ask you this question about spray versus wipe. There's no doubt, first of all, that spray will be aerosolized. And the employees over time will certainly be breathing this stuff in day in and day out. And that's not particularly healthy. But as far as coverage goes, do you think spray has better reach than wipes, given the fact that you have to actually physically reach the microbes with the wipe as you're cleaning and disinfecting the surface? My personal opinion is I think you get better coverage. And the reason I say my personal opinion is because there's conflicting research. When they actually do the studies where they stick the little, clear dots in random places and those clear dots act as little tiny petri dishes and then they gather them and they monitor, you know, where more germs killed with the sprayer, more germs killed with the wipes. It's also dependent on the user. And so part of the reason I like the wipes is because when I was at the school and we had a 25 chair dental clinic and just a few steps down the hallway, we had a six chair radiology clinic. And all those students were spraying all at the same time. That was a lot of aerosol at the same time. And we would have people complaining about getting headaches. But in your regular dental office, I really think, I mean, the numbers are very close in the research that I've read anyway. And if anybody has anything else, please send it to me. OK, so you did mention, though, you thought wipes had better coverage than spray. Or did I mishear that? No, I'm saying wipes in a private practice setting. Wipes stay moist, whereas there's less of a chance of like sometimes people do one spray. There's more of a controlled dosage was the road I was going down. When you pull a wipe out of a container of wipes, it's equally saturated. Right. Whereas sometimes people would be like one spray. Like I may have even heard employers say, well, you're using an awful lot of spray. Like, are you kidding me? I'm saturating it to the point where I think it's going to be effective. Yeah. So it seems to me that if someone's using a spray and they're using it very sparingly, they won't get the same results as someone who's using a wipe that's very meticulous with a wipe that's fully saturated, as you mentioned earlier. And the same goes true the other way. If someone is using a wipe in a very cursory manner and they're not fully wiping the surface down. vigorously and covering all the real estate that should be covered between patients, then someone using a spray very vigorously will obviously get better results. So it very much depends on the nature of the person who's doing this. It's more important in that situation what they're using. things are important but the what you're using and what's actually waiting the amount of time you're supposed to wait i personally when i work private practice i like the wipes better um i think the spray would work better if you use more of it so when you say it's more important the actual spray or wipe you're saying the chemical that's inside that wipe okay so what you're not using something like you know something over the counter or um I've even heard of offices that are just using a basic dish soap that's diluted that has some type of antimicrobial claim on it and using that to spray with. You have to have the chemical because that's what's going to give you that ability to have a broader spectrum of killing the bio burden. You're not going to kill the spores. You might kill some of the spores, but you're not going to kill all the spores. The other important thing is the viruses. Those viruses are teeny, teeny, tiny. And if you're not using something that's aggressive enough to permeate their layer or their capsule on that virus, then you're not going to get viral death. And that's the really important thing, especially during, you know, cold and flu season, COVID, all that kind of stuff. Yeah. So when you're lecturing. Emily, and someone says to you, I have a very high volume practice. We're very busy. We see a lot of patients. I need quick kill time and I use wipes. What do you recommend? 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I say find a disinfectant with a one-minute claim. I personally, I like the Opti33. I know there's a Henry Schein one that's a little bit less expensive that has that one minute kill time. The name escapes me right now. The other thing that's really important is that your team likes to use it. The people who are using... the disinfectant i think should get to choose what they're using because and not you know having five different types in the same office that's not good either because if you get a sulfur containing compound and then all of a sudden you put something with hydrogen peroxide in it your whole office will smell like rotten eggs so it is really important that you stick consistently to one brand within the same office setting. But I think that you need to get team input before you make a choice like that. Because if somebody is going to enjoy using it, chances are they're going to use it more effectively. Let's pivot a little bit and talk about single-use items in the practice. That seems to be becoming more and more popular. In fact, even diamond burrs, which is amazing to me, come in single-use packaging. You use them, they're really sharp, and then you chuck them in the waste basket. And when I practice dentistry, I use mostly carbides because that's what I use to access pulps with a high-speed handpiece in my endodontic practice. But diamonds were always considered to be a luxury item. And now they're being used more and more with the type of materials we're using, like zirconia and some of these ceramics. But they get thrown away after a single use, which does certainly prevent employees from sticking themselves and transmitting bloodborne pathogens. among employees just by cleaning them and so forth. So there's a lot of advantages to single use. And in the long run, the return on investment isn't too bad. It's probably beneficial to use them one time. But as I mentioned, we're seeing it more in the dental practice than ever before. And it's expanding across quite an inventory of materials. So tell us about that. Yeah, there's one time use items. It's an interesting ballgame. When I see a package. And it's packaged and it says one time use. I don't know if it's my level of ethics or if I just, you know, I see that. I think I'm going to use this one time and then I'm going to dispose of it. And then I have a student who goes out into a situation, a summer externship, who comes back and they're like, hey, Dr. Bogey, when you told us that you're never supposed to wash and reuse a nitrile glove. is there a nitrile glove out there that isn't like that because i was in the office and it's like oh dear mother mary like why why are people doing this and i i you know you talk about the diamond burrs which you know is a more extreme example than than a one -time use glove but i really think one-time use has to be one-time use if you're going to follow the package instructions and you're going to keep your patients safe there's a reason they make those sds sheets there's a reason that the government is requiring packaging the way they require packaging. It's to keep the patient safe and it's to keep the patient safe consistently. And so when you talk about a one-time use item, like if you're using those little tiny bite block XCP instruments that fit on your radiology CMOS sensor and they say one-time use, that means you throw them away. If you're using the kind that can go through sterilization, that means they go through sterilization. You don't spray wipe spray them. You put them through the sterilization process and they get packaged and bagged and run through either the steam sterilizer, the clave, whatever you're using. And so recognizing that they don't package this stuff with labels by accident. It's because we need to follow the labels. And until I don't hear somebody talking about. different ways that you can reuse one-time use items like oh my gosh do you remember when that board game came out a few years ago where the children had the the retractors that they would put in their mouth and then they would say funny words and the other kids had to try to figure out what they were saying i almost had a heart attack i'm like those are one-time use retractors what are you doing to those kids and they're all sharing it they're all sitting together passing around Yeah, that's how they develop their immunity, though. I grew up in the dirt, so I understand that. There you go. You're a fully grounded person. So one-time use items for sure. They are very important today with infection control. And the moral of your story in this podcast is follow the directions. If it's a one-time use, get rid of it as much as you love the environment. If that's what you're using, you got to get rid of that item and you can't reuse it for whatever rationalized thoughts you have going through your mind, whether you want to save the environment or save money, you're jeopardizing the patient by using that item a second time. So that's the moral of that story. And the other thing is there are some items that have historically been one time use that people are now able to develop that we can sterilize. An example of that is like the PureVac. a high vac tip it's a high vac tip with a mirror on the end that high vac tip is designed to be sterilized up to 100 times so that is a great example of sustainability, of eco-friendliness. I mean, there's many other products like that. But you have to say, what is this designed for? What have the manufacturers taken the accountability of going through the product testing and making sure that it's going to be effective the second, third, fourth, 88th time I use it? Yeah, I remember contra angles for prophes were sterilized. Now the whole thing is... in the trash. They'll make the kind that you can completely sterilize. And I do know people who are incredibly environmentally friendly, who have more time and patience than I do, who do use them. And they run them through the sterilizer every single time. And they lube them and they monitor the gear function and all that. It's a lot more work. But if you have the time, you know, whatever. Yeah. But again, chair time, chair side time is where the money's made. That's where the money is. And that's where the patients are being cared for. you have a busy practice, then that shouldn't be an issue. Tinkering with the contra angle of a prophy shouldn't be something that you should be spending too much time on. So let's talk about glutaraldehyde. That is something cold sterilization is something the, what is that? The killer blue juice, whatever that is. So the problem is it's not all blue anymore. Here's my beef with glutaraldehyde. They changed the color. Wow. Some of it's yellow, some of it's pink. Some of it's blue, some of it's green. Some of it has a 24-hour effectiveness wait time, kill time for scores. Some of it has 48 hours. Some of it has 36 hours. Then we have to talk about how long it's good. Some of it's only good for a week. Some of them... are only good for two or three days. And then you have to dump the whole thing and get more or mix more. The problem is there's no consistency. The blue stuff from one company, when you compare it to the blue stuff from another company. So like I saw this, like the kind we used to use when I was in private practice was yellow. Well, one time they accidentally bought and we had the kind that you had to replace every two weeks. And it was 24 hours effectiveness. So if I had, let's say, a reusable bite block and I threw it in the cold sterile, 24 hours after I threw it in there, it was considered sterile. I could take it out, rinse it off, reuse it. And it was sterile. The spores were dead. Then someone accidentally bought the kind that was effective after 36 hours and you had to replace once a week. But it was also yellow. You see what I'm saying here? My other beef with gluteraldehyde is at 8 o 'clock in the morning, I put a bite block in the gluteraldehyde. At noon, I put a bite block in the gluteraldehyde. At 4 o'clock, I put a bite block in the gluteraldehyde. The next day, my dental assistant sees three bite blocks in the gluteraldehyde, assumes, oh, Emily must put those in there yesterday. She must have had to prop up a whole bunch of mouse for sealants. So she rinses those off. Which one doesn't have spores? Yeah, there's no way to control it. Technically, they all could have spores because the 4 o'clock spore could have climbed over to the 8 o'clock situation. What you're saying kind of reminds me of what goes through my mind when I order French fries at a restaurant. I don't know how long the oil's been in there, and I know it has to be changed when they fry it. You could be getting the end of the batch, which could have been left there longer than it should have been, or you could be lucky and get the new batch of fresh oil, and then I guess fried food is not as bad. It's something to be aware of. Not quite as bad as what you're talking about with sterilization, because that's a very serious issue. And with me, sterilization is something we don't compromise. Yeah. Sterilization means that we're all using the same systems and we're doing it in a streamlined manner that everyone can follow. So when we go back to that individual who worked at the bank on Tuesday and now works at the dental office on a Thursday in the States where it's allowed. They have an easier system of learning, and it's a much more controlled environment. Now, the glutaraldehyde people might listen to this and be like, why does Emily have to be a hater all the time? It's because they're controlling situations in their lab that's proving their product is working. You get that into a real-world dental office, especially a dental office that has 18 or 20 ops, and it becomes not the most reliable system of sterilization. That's my beef with that. Less and less offices, you think, are using cold sterilization these days? Oh, yeah. And I think part of that is they're making the claves much more affordable. The statums are getting redesigned. People, as things get more affordable, the technology becomes more affordable. And these reusable products versus the sterilizable products, a lot of stuff, they design it to be sterilized, meaning going through the heat or the... chemical vapor or the dry heat situation, steam heat, chemical vapor or dry heat. That's what the companies are doing the testing with. Therefore, the glutaraldehyde is kind of becoming more obsolete. But I mean, if you had a certified dental infection prevention and control coordinator in your office who could write down those systems and make sure those systems were working and make sure everyone was trained in the use of glutaraldehyde, I wouldn't have as much of a concern. When you talk about a infection control coordinator, tell us what that is. And does it apply to only the larger practices where there's a lot of personnel or could even a smaller practice benefit from having an ICC? So in the 2003 CDC recommendations for dental practice for infection control, which in most states are considered law. So those recommendations in my state of Iowa, they're considered law, meaning if the CDC says it and they put out a document like that, states who it's not considered law actually have more prescriptive infection control regulation. Back to that discussion in 2003, it says that each office is required to have an infection control coordinator. And this coordinator assures that there's quality. and it does it doesn't get too prescriptive on what this person is to do it just says that each office is supposed to have one now in most offices i will tell you this person makes sure that you have your annual infection control training your annual HIPAA, OSHA, SDS training. They make sure that everything gets signed and all the logs for the records for spore testing and steam sterilization testing are being done and being retained. They make sure water control testing's being done. They make sure that bacterial... Water treatment is being done. So that's what most of these folks are doing in practices. Now, what I can tell you is recently I took the CDI PC test through the Dental Assisting National Board. Now, I'm a dental assistant. Originally went back to school for dental hygiene, went back to school, got a bunch of other degrees. But this year, you know, I lecture on infection control and prevention. all this stuff and i thought boy would it be nice if i could get some kind of designation that that shows my listeners that i actually took a test and i'm certified to be talking about this stuff now that test exists it's only about three years old so you can actually put the letters cdipc behind your name once you get this micro credential from danby and not only can dental assistants and dental hygienists and dentists get these letters behind their name But what's really cool is manufacturers can and, you know, people who work for corporate entities have been taking this test as well. And it's really cool. Like, do you need to have the test or the certification to be an infection control coordinator? No. it is just one more thing to say, hey, I can put this on my resume. I can write it behind my name. I can prove on paper that I'm a specialist in this field. So that's very interesting that dental team members can get that micro -credential with the acronym CDIPC, which stands for Certified in Dental Infection Prevention Control, something Danby offers. I think it's very important to look into that. And that's why we do these podcasts to get this information to our listeners. So we thank you for that one, Emily. Is that a written test only or is there a hands-on component to that? It's a written exam only and you have to take it at a Pearson testing center because it is, you know, it's a standardized test, but they're very serious about making. How long is the test itself? I believe it was a hundred questions. I just took it. Okay. So it's a couple of hours probably. It's as far as how much money. I think it was like $300. No, I mean, it took about an hour to two hours. You get two hours. Two hours. Yeah, I figured that. So I think that's a great thing. First of all, if I was a dental assistant that had that, I would make sure the dentist who's about to hire me understands that you have a built-in ICC now, if you don't have one already, or you have a backup ICC if that person leaves, or you can contribute. to the infection control and prevention protocol that your office is currently operating right now to make it better. And you probably get paid a little bit more, right? Absolutely. I think it's a marketable quality. It also shows you care. It's like if I have a really deep passion for remineralization and I take classes for, I don't know, silver diamine fluoride and fluoride varnish, and I take all the classes. And I then say to my employer, you know, I've taken all these additional classes and I would love to implement in your pediatric practice some camera and minimally invasive types of therapies. It's a practice builder for whoever's hiring you. And it's a marketable skill for yourself. And I think. This is what's really the dentistry of tomorrow is all these new things, being able to prove that you've been trained in all these new things like laser training and guided biofilm therapy and all this other stuff. Yeah, there's no doubt about it. I mean, I do a lot of podcast episodes. I talk to a lot of dentists, but I also talk to a lot of hygienists. And I'm hearing more and more that the dental hygiene field, the opportunity that's available today versus back 10, 15, 20 years ago, where Dental hygienists were expected to sit chairside, scale and root plane for their entire career, which some, you know, had no problem doing. That's what it was. Some of these speakers refer to it as the glass ceiling. That's what you're facing when you graduate hygiene school. There's much more beyond that today. And it's really exciting to see the opportunities. And like you said, remineralization, laser, speaking, teaching. Infection control coordinator. Yeah, these are huge things. There's so much opportunity and that's what's, it can be whatever you make of it. And the other cool thing that I think, you know, I don't want to get too political in the discussion, but there's a lot of dentists who really don't want to have all these other things that hygienists can do. They don't want to release these tasks to hygienists. My thing is not everybody's going to want to do it anyway. Like they can make a lot of things legal in my state. But I'm not I mean, there's already things that they've made legal in my state that hygienists say hard. No, I'm not doing that because they don't want to take the training. They don't want to I mean, they don't want to motivate themselves to have different things in their schedule every day. And so not everybody's going to do it anyway. And so, I mean, just make make the credential available and then people can make their own life choices. Yeah, for sure. And dentists are very dental practice owners are very busy doing so many things in their practice. That when a hygienist comes up to the dental practice owner and says, hey, Dr. Smith, I have this extra training. I'm trained to be an infection control coordinator. I see some gaps here in this practice. Would you be okay with me taking charge and giving me some autonomy into taking this to another level? And this will serve your practice, serve our practice very well because patients are going to start to see it. It's going to be a practice builder and everybody wins. And you know, what's really interesting is when I used to take new training, I would always hang my degree or hang my certification on the wall. And then patients would ask me, oh, you got laser certified. That's so cool. What can you do with that? Or why did you do that? And then you could say, well, you know, we wanted to do more to be able to kill the bacteria in your mouth. And so I did that. It's the same thing. Like we sent Angie to get her CDI PC because we really, you know, in a post COVID world, we really want to make sure we're keeping you safe. It shows the patients the value, the ROI of having, you know, trust. I mean, that's really some kind of things that are hard to quantify, but patients are going to stay with you if they trust you. Yeah. And again, another moral of the story that Emily's getting across here very well and articulately is when you graduate hygiene school, that's just the beginning. For sure. You have a whole career ahead of you. There's lots of opportunity. Get educated. Take continued education courses. Find a mentor. Emily's an amazing mentor, but she can't be a mentor for everybody. So you have to find your own mentor. But certainly listen to her and listen to many other KOLs that also have tremendous experience like Emily. Emily, thanks so much for your time. It's your discussions that make this podcast fun and worthy to our audience. Thank you very much. Yeah, you bet. Thanks for having me. It was so much fun.