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It’s not OK for your dental practice to use free cloud-based communication

June 10, 2021 By DentalBuzz Staff Leave a Comment

It was nice – the way that the HIPAA police looked the other way as we all figured out how to take care of each other during the worst of 2020 – but now that we’re over that hump, emergency usage is no longer an acceptable excuse for a security breach or a privacy violation.

Before you begin defending the use of cloud-based messaging in your office by explaining that you never share protected health information (PHI) there, or that you have other security measures in place to protect you from malware, or hope that the regulations only apply to large organizations and not small practices, know that there is one rule that is hard and fast when it comes to using communication tools in healthcare:

Only Paid Versions are HIPAA compliant.

This is because free versions do not include something called a Business Associate Agreement (BAA). A signed BAA is required in order for cloud-based systems to be HIPAA compliant. It’s not as though you’ll ever need to exercise an audit, but if one becomes necessary, this is the safeguard in place to allow you to have the ability to prove that a program such as Slack or Microsoft Teams was not the source of the privacy breach. Here’s the thing: even if you’ve never shared sensitive patient information on any platform, it doesn’t matter if you can’t prove it!

And that right there is the crux of the matter. While you may think this threat is a flaming fear spear, remember, data has value, and there are those out there who seek it out in order to further enrich themselves. We all have an obligation to follow the recommendations set for us professionally. After all, you’re a patient, too. Maybe not always where you work, but if you have a body, somewhere you’re a patient in an office’s system, and as such, you’d like to know that the practices you visit are managing all of their privacy matters correctly. If they’re no being careful with something simple like communications, it makes you wonder where else they’re making mistakes.

While this is not a comprehensive list, these are the most common communication platforms that dental practices (and healthcare practices in general!) may encounter when they’re looking for a way to collaborate with their team members, along with the current pricing that users should expect to pay in order to safely utilize the software anywhere in their business.

As you can see, it starts to get expensive, very quickly, if you’re dead set on using one of these platforms. They don’t even do a good job of getting the right person’s attention at the right time, especially if people in the office don’t just sit at one computer all day. You can get so much more for your money once you accept that healthcare businesses must have a paid subscription to use cloud-based communication. It’s just a matter of doing a simple Google search to find many other solutions more tailored to dentistry, at a lower cost per year, per user, per month, whatever. Making do with the programs above means that you end up paying for things that most team members aren’t even using, like Microsoft Word, or screen sharing, or video conferencing.

In case you’re still confused, here’s the concise answer for each of the free versions of these platforms.

Is Slack HIPAA compliant? No.
Is Microsoft Teams HIPAA compliant? No.
Is WhatsApp HIPAA compliant? Never.
Is Skype HIPAA compliant? No.
Is Google Chat HIPAA compliant? No.
Is Zoom HIPAA compliant? No.

And for final clarification, you can become HIPAA compliant in the use of five out of six of these applications, but only once you’ve paid a subscription fee per user, disengaged any non-compliant third party integrations (so many rules!) and received a signed business associate agreement.

Otherwise, it’s time to look elsewhere.

Resources:

HHS.gov Business Associate Agreements: https://www.hhs.gov/hipaa/for-professionals/covered-entities/sample-business-associate-agreement-provisions/index.html

Slack Enterprise Grid for Healthcare: https://slack.com/resources/why-use-slack/hipaa-compliant-collaboration-with-slack

Microsoft Teams for Healthcare: https://www.microsoft.com/en-us/microsoft-365/compare-microsoft-365-enterprise-plans

Zoom for Healthcare: https://zoom.us/healthcare

Patients ask, “Is it safe to go back to the dentist?”

August 19, 2020 By DentalBuzz Staff 4 Comments

The COVID-19 pandemic sucks.

Now that we’ve gotten that gross clarifying understatement out of the way, let’s quickly address the title of this article. Most likely, yes, it’s quite safe to go back to the dentist. You’re feeling a little scared to get your dental work done, or to get your teeth cleaned, still, because maybe, you don’t know what has changed at your dental office to assure that you’re not going to contract the coronavirus there.

To recap the last few months, non-emergency dental care was completely shut down for a while, which had less to do with patient safety and more to do with the severe shortage of masks and gloves. Now that manufacturers, opportunists, and supply chain managers are ~~going for the quick cash grab~~ able to provide adequate amounts of PPE to dental practices, visiting the dentist should be no more dangerous to your health than entering any other enclosed public space.

But! There’s this annoying thing about viruses and droplets and aerosols that make dentistry quite different from visiting most medical offices.

Like everything these days, it’s complicated.

You didn’t come here for the science or the reasons that dental offices have made changes. Instead, you simply want to know whether or not your particular office is doing the right things to keep you safe, now that they have had a few months to get used to new routines.

Abundant Safety Precautions and Screening

Are you being allowed to breathe, maskless, anywhere other than in a treatment room? Surely by now you’ve had to wear a mask in public, so if you’re permitted to enter a dental practice without one, consider that your first huge red flag that they may be cutting safety corners elsewhere.

Many dental practices are having patients phone or text their arrivals in from the parking lot, making it so that there’s no stop in the reception area except for a little screening time. Furthermore, team members may check your blood oxygen saturation, along with asking a series of questions and the usual temperature-taking.

Watch for: Touchless thermometers, plexiglas barriers, pulse oximeters (finger clamps), hand sanitizer, complimentary masks.

Anonymously Mummified Clinicians

If you’re not sure who is taking care of you, congratulations! Your dentist is under there, somewhere, but is not likely to come in contact with your salivary or nasal secretions as long as those layers stay in place. Some dentists have their well-protected team members wear not just nametags, but “facetags” these days, so that you have a face to associate with each human-shaped blob that hovers near your examination chair.

Also, you may need to bring a light jacket – the exam rooms may have the ambient temperatures turned down to reduce the heat exhaustion that clinicians feel under all of that gear.

Watch for: N95 masks, scrub caps, full protective gowns, face shields, sweating complaints.

Animal-Sized Airflow Management

The rationale here: if COVID sucks, dentistry must suck harder, quite literally. If there’s no control of where infectious particles end up, aerosolized viruses are allowed to settle in place or move from room to room. Instead of letting them linger and then finding their way into your body, new large suction devices are used to pull the air directly into a filtration system that traps virus particles, making the dental environment much safer for both patients and the office staff.

Another way that dental offices are knocking down virus particles is with a powerful virus-killing fog machine. You probably won’t be able to see indications that the office is using this technology, but it never hurts to ask how they are cleaning rooms between patients.

Watch for: Large air funnels, things that look like vacuum cleaners, faint chlorine smells, HEPA purifiers

Low Aerosol Dental Treatment

In dentistry, water is utilized as a coolant to keep drills and cleaning tools from getting too hot. Unfortunately, aerosols are a big no-no right now, so there will be only the minimal amount of water used during your visits. Expect your preventive dental cleaning to be delivered quietly, with the use of hand tools only.

You may be asked to pre-rinse with iodine or hydrogen peroxide before opening your mouth for the first time, and even may need to hold a cup to spit in to limit the amount of automatic suctioning needed. And don’t be surprised if your hygienist doesn’t apply any grit to your teeth. Cosmetic polishing has been known to cause excessive splatter, so most state dental boards are frowning upon allowing this procedure to be performed.

Watch for: Pre-rinses, hand scraping, spit cups, tongue-grabbing high speed suction, dry mouth

Isolation and Solitary Confinement

Even with all of the precautions taken, each clinician must be very careful not to contaminate anything outside of their direct treatment area while they’re with a patient. Doctors, assistants, and dental hygienists can no longer simply move freely through the office. Instead, they are expected to stay in place until full dental care is completed.

Simple tasks like asking questions and grabbing additional equipment is now largely left to those outside of a treatment room. This is because the time and costs needed to change gowns, masks, shields, and the like have significantly increased. Dental teams are learning new ways to work together, by relying on internal collaboration software programs that give a dentist the ability to stay with one patient yet answer questions about another one via their private computer networks. If you work in a dental practice you may find the article below helpful:

Practice Communication has Changed: Isolation in the age of COVID-19

Watch for: Computerized communication systems, waiting patiently, hand signals, excessive sharing of life stories

Coronavirus has significantly altered the way that dental care is delivered, probably forever, and probably for the better. If you don’t see any differences in how care is given the next time you visit your local practice – watch out! It may mean that, in your case, when asking “is it safe to go back to the dentist?” the answer is no.

References:

ADA News: Dentistry is essential health care. https://www.ada.org/en/publications/ada-news/2020-archive/august/ada -who-guidance-recommending-delay-of-dental-care

World Health Organization: Considerations for the provision of essential oral health services in the context of COVID-19 https://www.who.int/publications/i/item/who-2019-nCoV-oral-health-2020.1

Practice Communication Has Changed: Isolation in the age of COVID-19 https://www.bluenotesoftware.com/isolation-in-the-age-of-covid19

DOCS Education – S.T.A.R. WARS: Addressing Aerosols in Dentistry https://www.docseducation.com/blog/star-wars

A virtual care package from worried dental hygienists

April 2, 2020 By Trish Walraven 3 Comments

COVID-19 restrictions limit dental visits to all but emergency care, which means that millions of patients are overdue to have their teeth cleaned.

And because preventive services are not critical in the short term, all dental hygienists affected by the shut down are now out of work. However, the jobs will come back. What’s more concerning is the damage that may be happening in our patients’ mouths without a little extra intervention.

A few years back, do you remember the guidance that hygienists and dentists shared with you whenever we discovered that blue plastic bits were getting stuck under our patients’ gums? That was the dental community banding together here to get the word out, and we were able to convince manufacturers to stop adding plastic to toothpaste.

We’re coming together again in the same place, this time to pack a few personal items into your phone, tablet, computer, or whatever you’re looking at right now. This is the delivery we’re shipping to our patients, to take care of you with our thoughts and our hearts, and to share our best tips to make sure that you’re as healthy as possible at your next dental visit.

You want me to put my toothbrush where?

Care Package Item #1: Brushing your teeth with your other hand for the first minute, then switching hands.

This is all about about getting re-introduced to friction and tapping into novelty to help you learn something about yourself. When you pick up your toothbrush, you normally do so with your dominant hand. Instead (and this is THE KEY) you will grab your toothbrush with your other hand. If you’re a righty, then put your toothbrush in your left hand. Add toothpaste if you’d like and start brushing. Pay attention to how your gums feel when the bristles touch them. Most people don’t realize this, but they avoid touching their gums properly when they brush.

If it hurts to brush with your non-dominant hand, this is a sign that your toothbrush may be too hard, because soft brushes should feel pretty normal at this point. Keep brushing with your other hand, all around, then try to make the bristle contact feel the same when you place the toothbrush back in your dominant hand. It was surprising the first time I did this, because I realized I didn’t brush as well in areas that I thought I did. Even though I’m a hygienist, this helped me uncover weaknesses in my own brushing technique. Just watch out how you spit, because your other hand may now be in your trajectory field and end up all slobbery.

What’s your best flossing hack?

Care Package Item #2: Curved 3D flossers

As products go, this is a very specific one! There’s no substitute for using a string under your gumline, and if you have a tool that angles the string perfectly every time, you’re more likely to floss frequently and effectively. Make sure that your flosser is curved in 3D, not just flat:

With your 3D curved flosser, click the string between each place that your teeth make contact and floss deep under the gum tissue, once for each side, just like this:

I’ve demonstrated this on a front tooth for convenience, but the payoff of using these 3D flossers is when you get to really tight spaces in the back. My favorite brand is the Dentek Complete Clean Back Teeth, but there are others. Just make sure you purchase the curved flossers and not the flat ones.

Whoa, what should I do about blood or braces?

Care Package Item # 3: Soft Toothpicks

If you’re bleeding when you brush or floss, or can’t clean effectively with either of those items because of metalwork in your mouth, you’ve got to dig deeper. Remember, the stuff you’re trying to clean off of your teeth isn’t necessarily food; instead it grew there like a layer of pond scum, so you need to disrupt it as often as you clean your armpits.

Try gently poking deep into the areas that tend to bleed easily, like the gum pockets you’ve been told you have (that’s mine up there), or create some friction up in the gumline next to an orthodontic bracket or retainer wire. As long as you don’t feel any pain, you should be able to sweep away the germs that contribute to tooth loss with interdental cleaners like the Gum brand Soft Pick.

No toothpaste? Are you kidding?

Care Package Item #4: Brushing without toothpaste first

Hear me out – I am addicted to the feeling of mouth freshness. This is what the detergent industry has turned me into, a little mint whore. However, the foamy nature of toothpaste tends to obscure exactly what it is that I’m brushing, so periodically, I’ll spend the first 30 seconds of my brushing ritual without toothpaste. After that, it’s like an exciting reward, a delayed gratification of sorts. Hey, when you have to stay isolated from the rest of society for a while, the little joys start adding up.

Will overeating contribute to cavities?

Care Package Item #5: Swishing with water all day

A side effect of sheltering in place is boredom eating, which means excess carbohydrates fermenting in our mouths leading to a rapid increase in dental decay. To combat this, each time you eat, be sure to swish with a mouthful of water immediately afterwards. This will help you rinse away excess particles and acid. Remember – dentists are discouraged from filling cavities at the moment – they are more likely to be put in a position to pull an otherwise good tooth to get you out of immediate pain and danger of having a life-threatening dental abscess.

We’ve shared this article with you because we’re worried! Priorities are going to change in the coming months, and our careers are built on the foundation that patients should be able to keep their teeth for a lifetime with minimal professional care. Stay healthy, friends, and we look forward to seeing you back in the office as soon as possible.

Trish Walraven, RDH BS is a dental hygienist in the Dallas/Fort Worth area who is sad for so many of her colleagues that have lost their livelihoods. She would like to inspire her fellow hygienists and dentists to feel brave enough to share their concerns and best home care ideas so that we can begin the work of reconnection.

Lead Aprons feel so good! Here’s why.

October 30, 2019 By DentalBuzz Staff 2 Comments

Ever since you were a kid, you’ve known this: there’s a comfort that settles through you right before getting dental x-rays. You notice when the heavy shield gets draped over your shoulders and tummy that it’s a bit easier to relax, to open your mouth and let the dental professional twist things in your mouth at weird angles.

That comfort is called Deep Touch Pressure. It’s what swaddled babies feel with a tightly-wrapped blanket, what dogs experience when they wear a Thundershirt, and what up until recently has been known as a soothing technique primarily for kids and adults who are on the autism spectrum.

When Deep Touch Pressure is applied over a wide area, it switches the body from running its sympathetic nervous system to its parasympathetic nervous system. Deep touch pressure gives a sense that it’s okay to leave the “flight or fight” mode and settle into a “rest and digest” mode instead.

The sympathetic nervous system engages when you anticipate anything that is challenging, scary, or painful, while the parasympathetic nervous system is responsible for releasing feel-good endorphins, relaxing muscles, and creating a sense of peace and calm.

To review, then, this person has their Sympathetic Nervous System fully engaged:

Person holding mouth as dentist and assistant sneak up behind.

Next, look at this little puppy enjoying its Parasympathetic Nervous System response:

No rhetorical questions here. You know you could just be the puppy forever.

There are stories like this one from Dr. Spindel’s blog that tell of patients wanting to keep the lead vest on for their entire appointment as a sort of security blanket. Only unlike her, once the x-rays are taken, most of us are nakedly shocked back into anxious uncertainty with the removal of the deep touch pressure feeling.

Um, hello?

You know exactly where this is going, right?

More than just a heavy Snuggie.

Pretty much every retail and online shop sells Deep Touch Pressure products now. This therapy is found in the form of weighted blankets which are much more comfortable and heavier than lead shields so yay!

If you’re a patient who gets a little anxious going to the dentist and you already have a weighted blanket that you shelled out $200 for when they first became available, try bringing the blanket to your next appointment to see if it helps.

And for those dental professionals reading this, you might consider getting a few weighted blankets for your office. You can find them as low as $50 each but current pricing hovers around $75 these days. Here’s an inexpensive fifteen-pounder seen in the local warehouse store this weekend:

Need something a little more rugged? These weighted blankets from DentaCalm are available in different sizes, can be wiped clean, and come in two colors:

Dental fear is real.

Even people who have been going to the dentist forever get nervous sometimes, like it wells up from some organic “gonna get you” place in our primitive perimeter warning system. Deep touch pressure helps to inhibit dental anxiety. Except for the anxiety within the dentists when slinking into a dental chair to get their teeth cleaned when there’s an opening in the schedule. Their stress comes from the fear that they’re about to be exposed as a fraud by their hygienist if the dentist’s gums bleed even one little speck during their preventive care. Sorry, the weighted blanket is simply not going to make up for not flossing.

Feeling calm is better.

Instead of shaming dentists for their questionable home care, then, let’s all get the word out that weighted blankets are more than a fad, or that they’re used as merely an excuse to stay in bed longer in the morning.

Worried about the stigma or mood-altering effects of using laughing gas (nitrous oxide)? Weighted blankets create a similar sense of well-being without masks, drugs, or that loopy feeling. Many practices have already discovered the benefits of weighted blankets, and feature this amenity on their websites as one of the ways they make dental visits easier.

Please share this link with your dental professionals, your patients, and your friends. And as always, DentalBuzz does not use affiliate links or accept ad payments, so feel free to browse the resources list and share your experiences with weighted blankets (or any good deals you discover!) in the comments below.

Resources and further reading:

Can I please wear the heavy vest: https://lspindelnycdds.blogspot.com/2019/05/can-i-please-wear-heavy-vest.html

The Allure of the Weighted Blanket: https://www.brainfacts.org/Thinking-Sensing-and-Behaving/Sleep/2018/The-Allure-of-the-Weighted-Blanket-112918

Penn Medicine: More than just a fad: https://www.pennmedicine.org/updates/blogs/health-and-wellness/2019/february/weighted-blankets

HippoHug: https://hippohug.ca/2018/12/12/anxious-at-the-dentists-office-try-a-weighted-blanket/

TruHugs Research Blog: https://blog.truhugs.com/deep-pressure-stimulation-used-during-various-dental-procedures-to-curb-anxiety-symptoms/

DentaCalm: https:/dentacalm.com

Sommerfly Wipe-Clean Relaxer: https://www.sommerfly.com/collections/wipe-clean-collection/

What is this $&!% on my toothbrush?

September 4, 2019 By Trish Walraven 2 Comments

This morning I threw my toothbrush into the toilet. That’s where it belongs, apparently, since I can’t seem to do the right thing to keep germs off of it.

See, a few years ago there was a big news story about the aerosols that are created with every toilet flush. I call this phenomenon “Fecal Fallout.” Let me explain: if a toothbrush is stored in the open air near a toilet, the debris from the bowl can be carried into the air and then sprinkled down onto anything within a six foot radius in a plume of doom. As a result, we may find ourselves brushing with the e.coli germs from feces if we’re not keeping our toothbrushes covered.

So if we’ve been keeping them covered, that’s not good either? Covering causes yet ANOTHER PROBLEM:

The growth that you see in this and the following image was accelerated by a few days, but this is really what happens! If we close in the moisture on our toothbrushes, we might as well invite a whole slimy rainforest to grow in there. It’s not just our toothbrushes that are being over-helicoptered. Mouthguards also tend to grow things on them if left unattended:

Nope. No way. I welcome the Demons Of TMJ Disturbance to visit me and make me dream about my teeth falling out all night. Sad that I’d rather grind myself down to gummy nubs than to have to clean that nightguard off and sleep in it again.

When someone tries to gross us out with a problem, there’s a reason behind it, because there must be an answer, a solution to the horrible thing that we want to prevent. What I like is that this solution happens to be quite economical and user-friendly.

No. Not that economical. You’re going back to the whole idea of “things that should be in the toilet.” But at least you’re thinking dry.

The Toothbrush Shield

As a dental hygienist, at times I’ve been merely satisfied with knowing my patients are using a toothbrush, but lately I’ve decided to acknowledge that they can be vectors for pathogens to invade our bodies if not managed properly. What’s excessive though, is how there are all these UV blue-light sanitizers on the market and other expensive gadgets you really don’t need to keep your toothbrush healthy. Along that path, I discovered the one thing that actually makes a lot of sense:

These covers both wick away moisture from your toothbrush and provide a physical barrier between your bristles and anything you don’t want them to touch, like your family’s other toothbrushes, bathroom cleaning chemicals, or stray hairs. I will never put my toothbrush in another plastic case now that I know about Toothbrush Shields.

This product is so obvious that I’m surprised I’m just now finding out about it. I want to get the word out why wicking sleeves should be as universal to our lives as something like plastic baggies. This particular wicking sleeve is designed for your toothbrush, and here are the reasons why I am endorsing the Toothbrush Shield:

Affordable. A pack of 10 Toothbrush Shields retails around $4.00 at the time of this writing, and each one is effective for up to 7 days.
Simple to use. Slip the cover on right after brushing, then your toothbrush can go anywhere! Your bathroom counter, luggage, purse, kids’ backpacks for quick sleepovers. No fumbling for a way to protect toothbrushes from questionable environments.
Hospital-grade. The lightweight but quality material feels almost identical to the larger sleeves I’ve used to keep saliva and blood off of patient headrests in the dental practice.
Made in the USA. Not only that, the company is woman-owned.

Part of that last bullet point is how I found out about this product. In the United States, 97% of dental hygienists are women. Other than kindergarten teachers (see the 2018 Labor Statistics here), the rest of the professions aren’t even close to having this extreme gender skew. So a short time ago I was at a conference exclusively for the dental hygiene profession – for all these women, essentially – where I was given a few samples of the Toothbrush Shield. Mind you, I was carrying a trade show bag heavy with familiar toothpastes, flossers, mouthwashes, and brushes from all the dental hygiene exhibitors. But this one product stood out, especially since I’d never seen anything like it before.

That’s where the “woman-owned” part comes in. While the person who invented the Toothbrush Shield is not a dental hygienist by profession, she has the insight to realize where her biggest advocates are poised, and most importantly, who they are, and what drives them.

I’d like to introduce her to you. She is Susan Klinsport, an entrepreneur with a background ripe for solving the problem of germs and wet toothbrushes that she encountered in her personal life. Her experience working with engineering companies gained her the access to materials testing, scientific consultations, and manufacturing, and has resulted not only in the Toothbrush Shield, but she has also designed the larger version as a Mouthguard Shield.

I didn’t snag any of these Mouthguard Shields at the conference, so I asked for some images from Susan herself. I know, right? She’s like totally my best friend now. That’s because after the show was over, I was like “Hey,” and she was like “What” and I emailed her to ask about her story and everything. And she was really cool about it so here we are, on DentalBuzz, getting the word out about a simple, effective product that will protect yours and your patients’ toothbrushes by keeping them covered every day, and that takes the place of plastic cases and rolled up toilet paper when traveling.

So where can you get Toothbrush Shields? Probably just down the street! You’ll find them in stock at CVS, Walmart, and Rite-Aid. Or if they’re not on your local pharmacy shelves, you can purchase online from many retailers, including the IntellidentProducts.com website that will take you to the Walgreens retail page where a box is on sale for $2.28 currently. Good deal! Even if they’re privately labeled, they are still the same product, as you can see below:

Critical Cleanliness

Patients undergoing cancer therapy are especially vulnerable to secondary infections, so oncology clinics and individuals are able to purchase Toothbrush Shields in bulk here on the website at SideEffectsSupport.com, the world’s leading resource for minimizing oral effects of cancer treatment. The shields are also included as part of the Oral Cancer Rescue Kit as pioneered by Jill Meyer-Lippert, RDH of SideEffectsSupport.com and Jennifer Brown, RDH, BS of CARTI Cancer Center in Arkansas.

Aetna has gotten the message as well. The insurance company is currently including the Toothbrush Shields in their oral hygiene care packages as part of their Rush to Brush program, thanks to the efforts of Susan Klinsport and Dian Baker, PhD RN. This program is designed to decrease patients’ risks of acquiring infections during hospital stays.

Final words

There is also a great news story featuring Susan and the Toothbrush Shield that I wanted to share here:

I’m now using the Toothbrush Shields over my manual toothbrush as well as my electric ones. Why so many brushes? It’s because I’m currently going back and forth, comparing my previously shelved Philips Sonicare with the new Braun OralB that I received for free from the same conference, but that’s a story for a future article. All have been easier to remember to re-cover, and I’m looking forward to traveling with them now instead of closed-in plastic caps that I have to keep up with.

As for the toothbrush I threw in the toilet? It’s got a new job: scrubbing the dark grime out of the washing machine.

Trish Walraven RDH, BS has been curating DentalBuzz.com since 2008 as a casual place for dental professionals and their patients to explore dentistry in ways that make their lives better. This does not include firm toothbrushes, which is probably an equal factor for tossing that one that ended up in her laundry room.

Disclosure and copyright: Other than the samples, I did not receive any other form of compensation for this article. Feel free to share this information on your dental blogs, social media pages, or any habitats where patients and colleagues tend to dwell.

Resources and further reading:

https://www.allure.com/story/toothrbush-germs-bacteria

https://www.usatoday.com/story/news/nation-now/2017/04/06/youre-probably-brushing-your-teeth-fecal-matter/99785026/

https://www.onhealth.com/content/1/toothbrush_germs_facts

https://www.guardiandirect.com/resources/articles/shocking-facts-about-your-toothbrush