Reducing the Risk of Aerosol Transmission: How Clean is the Air in Your Office?

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. SARS-CoV-2 shed new light on aerosol-related hazards in dental settings and illuminated the need to improve the quality of the air we breathe at the office. So the question is, how do we know the air in our office is safe? We certainly don't want air transmitting disease to our employees and to our patients. To help us answer this question is our guest, Linda Harvey. Linda is a healthcare risk management and compliance expert who helps dentists and teams navigate regulatory requirements. She's the founder and chief knowledge officer for the Dental Compliance Institute. Before we get started, I would like to thank our sponsor, Health First. Health First is a cutting-edge and highly respected company that helps dental offices across the country cost-effectively manage the complexities around medical emergency preparedness, infection control, medical waste, and regulatory compliance. So feel free to learn more about Health First by visiting healthfirst.com. Linda, it's a pleasure to have you on Dental Talk. Well, Phil, it's my pleasure to be here with you today. Thank you very much. Yeah, we're very happy to have you, and we know how busy you are, so it's a real pleasure for Viva Learning to have you on this podcast, and you have so much information that you can share with us that we really can benefit from. What is the relationship between air quality and disease transmission? You know, Phil, air quality, whether it's indoors or outdoor air, is very important for our health and our well-being. And interestingly, according to the EPA, the air in our home or office can be between two to five times more polluted than the outdoor air. and then you couple that with the fact that airborne transmission is one of the three primary ways we spread disease, you begin realizing that the indoor air quality has a direct impact on your personal health and well-being, as well as that of our patients. So when you think about how can this happen, airborne diseases are bacteria or viruses, and that's what's most commonly transmitted through small respiratory droplets. One thing that's also interesting is the fact you don't have to be in the same room as the person who just sneezed or coughed, because depending on different variables, though, like the size of the droplets, the type of the ventilation, or any other preventive measures that have been put in place, you may be walking into a contaminated space and then inhaling, you know, the pathogens from that patient or visitor, whoever. Yeah, and this has been going on for a long time. I mean, even way before COVID, COVID's brought some attention to the quality of the air in our office, but we've been... operating as dentists in dental offices within the same environment forever, right? I mean, all of a sudden COVID comes and we do have to be more aware of it, but we should put it in perspective that, you know, we've survived up until now with the air we have, but we're always looking to improve things. So what recent findings on air quality and airborne transmission of COVID-19 have you discovered? Well, when you look at some of the studies that have been conducted on COVID-19 in the past couple of years, there's an in vitro study that said that SARS-CoV-2 was detectable in aerosols up to three hours. So when you think about that, that really brings our awareness back. How long is SARS-CoV-2 living in our dental practice if we have a suspected or even a known patient with COVID or even a team member? So we'll talk about some of the layers of measures of protection in just a few minutes. The SARS-CoV-2 may live anywhere between 4 and 72 hours on hard surfaces. And there's been a recent study from Japan, I believe, I think it's still in the peer review process, where the researchers talked about how long the SARS-CoV-2 virus can live on skin and plastic. Thankfully, we're washing our hands numerous times a day, yet that still can be, you know, worrisome thought. And then it's also been isolated from saliva of infected individuals. And that research has been found by numerous parties who have conducted research on saliva. So that's not new. So if we have a patient who doesn't know they're positive, and there we are with our aerosol generating procedures, ultrasonic handpiece, high-speed handpiece, then that's going all throughout the operatory if we don't have layers of protection in place, Phil. Yeah. No, there's no question we need to be aware of this. I just want to throw panic across the dental profession. I totally agree because we, you know, I live, I will admit this. I was one of those dental professionals that lived through the no gloves, mask and glasses days. So, you know, pre-bloodborne pathogens. So when that went into effect in 1992, it was literally like, if we can use our analogy, pulling teeth, I didn't want to wear PPE. And we lived through it. We survived. We got used to it. And we wore PPE that was designed to protect us from bloodborne pathogens, not necessarily airborne transmission. So I think our awareness is heightened because of the pandemic. And that's not necessarily a bad thing in some ways, because if we can make our environment safer for all of us, patients and team members alike, we're all healthier in the end. Yeah, I know. I agree with that. What current trends have been identified and what recommendations and regulations should be considered at this time? Well, Phil, first I'd like to remind our listeners that concerns over aerosols, again, are not new. And I'd like to consider the fact that back in 2004, there was a great article in JADA, the Journal of the American Dental Association, in which Dr. John Molinari outlined sort of the, I'm going to call them hierarchy, for lack of a better word, of the aerosols and dental setting. And he said that the ultrasonic scalers and sonic scalers are considered to be the greatest source of aerosol contamination. And then air polishing. And then finally, you get down to about the third level up in his chart is the high-speed handpiece. So when we think about what we've been facing all along, and then we couple that with what OSHA has said in the past two years, as well as the CDC interim guidelines. And OSHA has been very consistent. And I'm going to read something briefly, if you don't mind. But OSHA has stated surgical masks are regularly used in dentistry to protect mucous membranes of the mouth and nose. from droplet spatter, but they do not provide complete protection against inhalation of airborne infectious agents. So when we think about how we've been protecting ourselves in the past and we're looking at how the changes we've had to make because of this pandemic, obviously we need to be looking at, you know, and should be wearing N95 respirator masks for aerosol generating procedures. And then what other layers of protection can we add into the practice just to enhance what we perhaps already have? Yeah. Many of the dentists that I talked to started wearing face shields and they actually like it. I mean, of course, there's a barrier between the patient and the doctor through this plastic face shield. And it's a physical barrier, but in some ways it's kind of an emotional barrier where you don't feel like you're really connecting to your patient like the old days. But, you know, some dentists don't like it at all. But I did speak to quite a few that are very comfortable with that face shield and they feel like, you know what, all that spatter that's been going all over me. for years is at least getting caught. She looks, this one, the KOL, looked at her face shield after one patient and said, oh my God, is this what was going to be all over my mask and face? So that's something that is relatively new in our practice behavior. Although, as I mentioned earlier, the infection control protocol that most of us carry out in our office on a regular basis really does the job for the most part. Now, I know that there are air purification systems. which is another level of protection which became popular after COVID, what strategies should dental practices consider for air decontamination and how to improve their air quality when it comes to air purification? Perfect. Yes, that's such an important point, Phil. So let's look at two different strategies for practices. One is first to make sure you understand how updated is your heating and air conditioning system. So what's the air circulation that you're achieving in your practice? a result of having a good heating and air conditioning system. So knowing what your MERV rating is, your minimum efficiency reporting value, MERV, is important. So once we know what the MERV rating is, then we know, okay, well, we've got, yes, we have a great MERV rating. It's a 14 or 16, which is the highest. And we have HIPAA filters on that. So now we started a good place. But many of us don't have that because our building is older or our dental practice is located in other... the building that has other types of businesses and it doesn't have the same air exchanges. So we have to then look at what can we do within our individual offices and operatories to purify the air, if you will. So when you think about air strategies, you can purify the air with typical air filter devices you could buy from an over-the-counter store, hardware store, medical supply store. There's different varieties that you can choose from. So when you're looking at air purifying devices, Evaluate, do they have a HIPAA filter? What size particles are trapped by this filter? Does it eliminate odors or not? What's the maintenance of taking care of this device? And is it really intended for healthcare use? You know, especially when we're going to put it up against aerosol generating procedures. What might be fine for a home or general office or the front office area in our dental practice may not be the best for our treatment rooms with aerosol generating procedures. So looking at those kind of devices, I know that there are several quality brands on the market like Medify. And then you can look at a large hardware store and buy something over the counter like a Pure device. And I've looked at those two devices when I've done some research. And they filter out quite a bit of dust and pollen and bacteria. And many times they have a claim of capturing particles of small of 0.3 microns, which is the size of the coronavirus. And that's great. But then we need to go one step further. And then I would look at a step where you're actually really purifying the air and you're really cleaning the air. And one product that I like here is ActivePure. And they have different types of devices as far as for the size of that space. One of their brands is a class two medical device, which I think is pretty unique in the market. But devices like ActivePure have a proactive and continuous technology. Pulling air in, but it's also putting out continuous molecules, oxidizers that are releasing back into the air that kill the microorganisms. So it's constantly disinfecting our air in a very safe and healthful way. And it's important to think about where we come in our technology in the past two years, because when I first started looking at air purifiers two years ago, My eyes would roll back in my head, Phil. I said, what do we need to look at? What's most important? And now that we have two years worth of information behind us, I realized that looking at a higher level technology is really important when you add in those layers of protection in your practice. So where would ActivePure, is that the one you use in your practice? Yes, uh-huh. Yeah, so ActivePure, let's just use that as an example, and you're familiar with that. Where would you put that? physically in your office? And what kind of footprint does that take in the operatory? Perfect question. The footprint is very small, smaller than, say, one of your scanning devices. It's very small. And ideally, you want your air purifiers towards the foot of the patient's chair. So in an ideal setting, if we had control over where our heating and air conditioning vents were coming in, you'd want the vent over your head, the patient's head. So the clean air is coming in over your head, which would delight all of our dental team members because we know how hot they are with all the PPE now. So you've got clean air coming in over your head. And the device is at the foot of the chair as well as the vent. So the air is being drawn to the foot of the patient chair and being circulated out and not being drawn out into the hallway where it can spread to other areas of the practice. So that's the ideal setting. One of these units would be used for an operatory. And then if you have another operatory, of course, you would have to get another one. But for areas where we're not generating procedural aerosol, like the front desk or the back office or wherever, those could be. more non-medical types of devices that you can pick up at a hardware store or something like that? They possibly could. It depends on what the practice wants to do and their philosophy and what they feel comfortable doing. For example, the ActivePure models have different models, different sizes that cover different size areas. So the smaller models will be ideal for, say, an operatory. Larger models would be ideal for a different space, like a business space or a large break room. And then, like you said, if a practice is comfortable with something that's more general and they're not looking for that continuous technology to continuously clean and purify the air, then they could certainly choose other brands that would work well. You're one of the experts in the profession on regulatory compliance, right? That's your specialty. That's one of your specialties. You work with HIPAA and other regulatory issues that affect the dental office. Do you think air purification going forward because of what we're experiencing now with COVID is going to be standard where it's going to be something that's required by dentists or is this just a nice to have? I definitely think it's more than a nice to have, Phil. I think that when you look at the CDC hierarchy of controls, we've got, you know, when you look at that inverted triangle, the least effective is PPE. Then you move into administrative controls and then environmental controls. So I think it's here to stay. And also we couple that with the fact that OSHA has an infectious disease standard on their radar. It's been on their radar and on their agenda for the past 10 years, a little more than 10 years now. And depending on what's ebbing and flowing in the regulatory environment at the time, it comes off the agenda and gets put back on. It was put back on the agenda last year, and it got pushed into from 2021 to 2022 here. And it's scheduled to be looked at again in April. So I feel like we're going to see something. It's probably going to be going through the regular rulemaking process. So that means it's going to be longer than shorter. In other words, it won't be an emergency temporary standard that will be issued and pushed through quickly. And I really feel like there's going to be some, they may not come out and say, you must have an air purifier. But when they look at environmental controls, that's what they're talking about. Do you see in the future of dentistry that this is one of the pieces of equipment that is part of the normal armamentarium of an operatory? That is coming down the line. I think it's coming down the line, and I think offices have already implemented technology, and I think they're very happy with it, and I think they feel safe and comfortable with it. And then my goal would be for them to look at two years into it, reevaluate the products that you chose, make sure you chose the good technology and the best products that's available, because like anything else in our practice, Phil, whether it's a high-speed handpiece or your sterilizer, nothing lasts forever. Yeah. No, there's no question about it. If you're going to invest in an air quality system, that's a piece of equipment that's going to be in your operatory. Why not buy something that's built to last? You don't have to worry about it because otherwise you're going to be replacing it. You're going to be repairing it. You're going to find out that it's not doing the job that it's supposed to do. So the piece of equipment that you recommend is ActivePure. And I think that's distributed by Health First. Correct. So for anybody that's looking for more information on this, you can visit Health First. which I mentioned in my introduction to find more information about it. Thank you very much, Linda. We appreciate your input. That was a great podcast. And we look forward to you doing more things with Viva Learning, webinars and podcasts down the road. My pleasure. I would too. Thank you very much. Thank you.