The Future of Face Masks in the Dental Operatory Post-Pandemic

You're listening to The Dr. Phil Klein Dental Podcast Welcome to the show. I'm Dr. Phil Klein. Today we'll be discussing the use of face masks in the dental operatory and how COVID-19 has forever changed the way we manage respiratory protection for our dental team. To tell us more about this is our guest, Dr. Sherry Doniger. She's a respected dental clinician, author, educator, and consultant who currently practices dentistry in Lincolnwood, Illinois. Dr. Doniger, it's a pleasure to have you on the show. Thank you, Phil. I'm so excited to be here talking about my favorite topic, infection control. Yeah, absolutely. And you have a lot of experience with that over the years. So we could say it's irrefutable that the conditions under which we practice dentistry has changed dramatically since March 2020. I think we all feel that. So based on what we've learned from COVID going forward, how are you protecting your team and patients from spreading respiratory diseases in your practice? Great question, Phil. COVID actually took a lot of us by, you know, shocked, you know, when we had to close our practices on March 17th. The majority of us did. And we put in place a lot of engineering changes in our practices. But the one thing I'd like to say, dentistry has always been awesome at infection control. Ever since the start of the AIDS crisis and the Kimberly Borgalis issue, Dentistry has always pretty much been in the forefront of infection control, and we have truly done an amazing job masking and disinfecting. We built on that standard of excellence, and we continue to add more things. I think that we have always worn our masks in our practice. In case there was any water droplets on it, we would change them. Now, when you're wearing a shield, it's not that big of a deal. You don't get the water on the shield as opposed to the mask. But I think moving forward to protect my team and my practice, we will continue to use all of the engineering changes, the air purifier, the hypochlorous acid spray, the fogging in the office, masks, eye protection. face shields and just be very diligent. And also, I think before this all started, We were like, oh, you got a cold, you got a cough, sure, come on in, no problem. Now I don't think practices are doing that as much anymore. I think practices are focusing on not only the health of the patient, but the health of their team, because they don't want a team member down. We are still asking patients to fill out questionnaires for COVID, for symptoms, and they do. And if people come in and they start to realize that those symptoms sound... a little suspicious, they wind up getting themselves tested. But if they also see that they've been sniffling a little bit, they will be proactive and cancel as opposed to getting to the front desk and saying, oh, by the way, you know, I've been sneezing all over the place. I should probably have canceled this appointment. So I think in that aspect, we're definitely keeping our team much healthier. And, you know, in the end, it's all about providing excellent patient care with a healthy team. So what have you taken from your experience during the pandemic that will remain in your practice? You did mention that you're going to continue with the shields and the fogging. Oh, Phil, the shields have put a huge light on my practice. As you know, I was a hygienist before I became a dentist. And all the ultrasonic and all the air polishing and all the sprays and everything, nobody knew before then exactly how many droplets we had. Kicked up in our face during a normal procedure, but with the shields you could see now what you have on your face after any any dental procedure, be it preventive or operative. So definitely we'll be keeping up with the shields, definitely we'll be keeping up with the fogging, and certainly we'll be using masks. During the pandemic, the height of the pandemic, we were doing more KN95 and 95, and we've now switched to a level three. Level three is a step down from that aspect, correct? It is. It's a step down, but with all the other mitigations that are in place, we've opted for a little bit more comfort. We feel that previously, before COVID hit, we were fine and healthy with using level one and level two. And I feel now that going to a level three mask is probably the best for our practice and our patients. Now that the levels of SARS-CoV-2 are declining and a variety of states have adjusted their masking requirements, where do you see the future of masks in dental practice? I think we're probably going to be moving totally away from level one. I guess one thing that I did fail to mention... And what we're doing in our practice is we're still asking our patients to mask when they come into the practice and mask until they are ready for treatment. I think that the level one masks will now be for patient distribution. If you don't mind me giving you a little bit of info here, but the masks are rated on a level through the American Society for Testing and Materials. I'm sure everybody has seen this ASTM on the boxes. of masks. This is a society and it's developed international voluntary consensus standards to rate masks. If a mask has this rating, they've been proven to offer a specific level of protection. And the masks with that have been rated for three or higher offer the best protection against coronavirus, the flu, the cold, or any other dangerous droplets, as long as they're staying dry and clean. And they're much more protective than the level of one or two. A mask with a level of one will keep up 95% of the particles measuring three microns and up to 95 % of the particles measuring 0.1 micron, which is, you know, 95% is 95%. Level two is 98% of 3.0 and 0.1 microns. And level three requires 98% filtration for all of the particles. So the level three is a better mask. It offers much more protection. And then when you go into the the N95 and the KN95. The N95 will filter up to 0.3 microns, and the N99 will filter 99% of 0.3 micron particles. But they did prove that they were a little uncomfortable to wear, and some people with respiratory issues were having a lot of difficulty breathing with these masks. Let me ask you this question, though. Regarding the three levels, and I know scientifically you talked about the particle size filtration and so forth. But let's put it in terms of clinical application. I think a lot of people use level ones. I use level threes for everything before COVID. But I think a lot of people use level ones. I know medical offices, they pretty much use level ones, but they're also not four inches away from a patient's open oral cavity with droplets flying around all over the place. Going forward now, after COVID, is it something that we should be considering? clinicians to eliminate level one completely and focus on minimally level two and level three, level three for aerosol procedures, right? Is that what we're looking at? Aerosol procedures for level three and non-aerosol procedures level two is acceptable? I guess you could say that, but honestly, I would stick to level three for everything because of space. Where are you going to put all these thousands of masks that you're ordering? We found just to simplify things, we only get one type of mask, which would be the level three. So then we don't have to make a decision. Well, if this is just an exam, but what if it rolls into something that's different? And so I just, I would prefer just to stick with one. That's totally my preference. The cost of a level three, though, is higher than a level two. Right. Just to clarify that. The cost of a level three is higher. I think that there had been some supply chain issues, especially during the pandemic. There were some issues and masks got up to, you know, forty five, fifty dollars a box, which was a lot of money. But things, prices have pretty much stabilized now. The cost factor isn't as big as the safety factor. I would much rather be safe and spend a little bit more money than worry about saving a couple of pennies. And I think that the level three masks are just constructed with just a little bit more, you know, you want to make sure that your masks have a high level of fluid resistance because you want to make sure that there's no splashes of blood or sprays of saliva. Obviously, then you would change the mask out because you don't want to come. in direct contact with any, any contaminants that are out there. So again, I would much, I feel much safer. I feel that my team is much safer and I could go to sleep at night a lot easier knowing that my team is safer with a better mask. Right. And after each patient using a level three, you discard that mask. Yes. OK. Yes, you should. You absolutely should. That's what that's a standard of care is that it's a one time. That's what single use products are. Any single use product that we use in our practice is, you know, a saliva ejector gets tossed. This gets tossed. It's just that's what we have to do. So let's talk about level three masks since, you know, you're obviously a proponent of using them throughout the day for all health care providers in the dental practice. What do you look for in a level three mask as far as the right mask to buy? Well, there's a couple of things I look for. For three years, I was wearing a mask that had a lot of volume in it. There had a lot of breathing volume because it was more like a cone. And I'm looking now for a mask to kind of replicate that when the mask is behind my ears. they're not completely sitting on my nose and my mouth. So I have freedom to speak. And I think that to me is a big, very huge factor to be able to have space so I can talk unimpeded. And my patients can understand me, even though they all think that we take a course and, you know, mumbling and they can't hear us anyway. But a mask size is, you know, the other thing that you have to remember is a mask size is like Goldilocks in the chairs. Some are too small, some are too large, and some are just right. You really need to find a mask that fits your face. My face happens to be small. You know, there's some of my colleagues that need to have a bigger mask, even something that would feel comfortable on my face. certainly needs to have uh you know they need to again have that space so you can talk and not be sort of chewing your mask while you're having a conversation with a patient um you definitely need a mask that provides coverage and one that's going to allow you to breathe you know the mask needs to go below your chin it needs to be tight enough uh that you know you feel that the you know that the protection is there and um cranberry happens to make a mask that has a lot bigger breathing volume than any of the other masks that i've been using lately uh it just it just seems like it's lighter and it does it does happen to fit my face they have several different types and i found one that really fits my face very well the quality control issue is something that dental offices need to pay attention to because sometimes these companies will send packaging to china and other places around the world and then these different Companies that bid out the lowest price fill these boxes up and then they get shipped out. So even though they all have the same label on them and they're in the same box, they're made by a variety of different manufacturers. Some may be good, but some may not. But I think with companies like Cranberry, it's important to understand the quality control. I am not a fan of gray market products. And when it comes to protecting my health, my team's health, and my patient's health, I really want to make sure that we have quality products that were manufactured under. rigorous standards. Cranberry, as you mentioned, does have these rigorous standards. I think people need to be aware that you get what you pay for. And you're right, there's masks that you can buy on a very popular online retail site, let's say. or a very popular warehouse store that say that they're level three and there's no proof that they are or they aren't. I highly recommend that all practices look into companies such as Cranberry that have exquisite high standards of care in production and nothing will be slipped out that's not going to be to their high level. And Phil, in addition to stringent quality control, one thing Cranberry does a lot of things right, but one thing that I love that Cranberry does right is they have a mask that has an inner layer enriched with aloe vera. vitamin C and vitamin E, they just feel better on your skin. And as a clinician that had rosacea earlier in my career, the feel of, you know, a nice soft mask on my face without the scratchiness and all that other stuff is incredible. So that's, I think it's called the ACE mask. Have to check that out. But it's certainly something that I personally, that's my personal new favorite mask. So moving forward, do you see yourself going back to N95s or KN95 masks, or will you stay with the higher level of filtration that's offered through the level three? No, I can't see going back to that in practice. I may wear one when I'm on an airplane, but I can't see going back to any of those other masks. I think level three with the face shield, with the air filtration systems that we have in place, our team will stay at this protocol until any kind of heightened level of community infection. occurs if something happens that we don't know about. I know in our state, the governor's and our health department sends us messages all the time about certain areas that have a heightened level of infection. So we will continue to use the level three masks probably as long as I'm practicing. Yeah, but you're still inventorying the N95s, right? Don't you want to have that in your practice, Dr. Doniger, in case there's an emergence of some new strain or something? And then they'll say, you know, CDC says, okay, we have an emergence of a new strain of a virus and every dentist has to be working with N95s as of Monday morning. You don't want to have to start looking for this. Do you inventory it? We do inventory it. But as of right now, as I said, we're going to stay with that with the protocol that we're using now unless there's a heightened level of infection that comes around. Because right now it seems like I mean, you look around the country and, you know, you look around everybody. Very few people are wearing masks. Everybody feels much more safer, even though it's flu season. I think that people I think that we are. going to keep what we have, especially considering the nightmare that it was to get all these products in our practice, that we couldn't get masks, we couldn't get face shields. So I believe everybody will be having an inventory in their practice. I'm just curious, Dr. Doniger, with your experience in your practice and your experience in infection control in general, since COVID especially, have you seen a shift in the behavior of dental patients as far as their awareness and their... in understanding better how a dental practice carries out their infection control and prevention? It's funny you ask that question. A year ago, I had a new patient walk into my office and I said, who can we thank for referring you? And she said, the internet. And I said, really? And she goes, all of the things that you write about, your high infection control standards were talking to me. And that's where I wanted to be as a patient. And I think that I have patients that know, I mean, they see us wipe the room, you know, they don't see us wipe the room down, but they know we have the air filtration. They know. And I think for my patients, the existing patients, the ones that were there pre-COVID and during COVID. They knew what we did. We always talk about it. We talk about fogging. We talk about everything we do. We talk about here I'm opening up the sterilization pack with all the instruments that we're going to be using. And this is sterilized and that's sterilized. And they knew that. And my practice is a little different because my patients have a level of expectation and they knew that we have this high level of infection control standards. And the new patients are just very happy. that we, you know, they're happy to know that they're coming to a safe dental home. No, that's really fantastic. I mean, you know, there was a time before COVID when ways to build your practice through word of mouth was to enhance your technology in your practice. And I think that still holds, definitely still applies. You know, if you have an advanced x-ray system and scanner and CAD CAM, you know, one visit dentistry, all this stuff was hugely impactful on the dentist's perception. the patient's perception of the dental practice, which helped in social media and word of mouth. But then COVID came and all of a sudden, I think infection control and how aware and meticulous the dental office team is related to managing infection control and prevention, that became the overwhelming criteria for a patient to decide whether they want to go to that practice or not. It is. It is a selling point. People come in and they look around. Whereas our office wasn't cluttered to begin with, there's less clutter now. And we still only have one patient come into the reception area at a time. And people appreciate that. And they say, they just know that we're safe. And to me, that's the biggest plus ever. So even now, you're doing one patient in the reception area at a time, which actually works very well with this flu season, which is out of control right now. Yes, that's interesting. It seems to me you're a minority there. I am because I talked to some of my colleagues and, you know, I actually had visited a colleague in her practice the other day and she had out like a treat tray, a little hot pot that you can make coffee or tea and snacks and cookies. And we never had that. The only thing I have in my office is a bowl of chocolate. because I believe that patients need a little bit of chocolate after they have a dental procedure, and it's been there all the time, and they kind of like it, and they kind of know it's me, but we don't have anything in our reception anymore. We stopped all magazines. Well, we didn't stop them. I get all my cooking magazines at home now, but we don't have clutter. We don't have anything, and it is one person at a time, and honestly, um we still have that extra 15 minutes built into our practice between patients um and it does a couple things it gives my team time not to not to stress and not to have to worry about getting the room done and cutting you know accidentally forgetting or or not doing something and it also gives us a few minutes to you know take a break between people and uh and as and clean the room out it's You know, for me, it's not always about money. It's just about the safety and the mental health and the practice. Yeah, Dr. Doniger, it's been a phenomenal time here, this short period of time we had with you on this podcast. You brought some really key things to light, which apply to where we are now post-COVID in the world of face masks and what we're looking at going forward with minimal protection being level three versus one and two. These are all key points. I think the profession is moving in that direction. I agree totally. And let's hope we don't have to go back to the N95s and we don't have any, like I mentioned earlier, some strange emergence of a new virus that sets us back again. Thank you so much. And we look forward to having you on future podcasts and webinars on Viva Learning. Thank you, Phil. It was an honor to be included.