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

August 19, 2020 By DentalBuzz Staff 6 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

Free “return to work guide” from the American Dental Association

April 27, 2020 By DentalBuzz Staff Leave a Comment

Did you try to access this guide on the American Dental Association website, but have decided that you don’t want to share your email address with them? Instead, use the link below to view the ADA COVID-19 pandemic recovery guide immediately:

https://success.ada.org/~/media/CPS/Files/Open%20Files/ADA_Return_to_Work_Toolkit.pdf

As a bonus, if you’re in Texas, or are just nosy about the current guidelines for dental practices reopening in this state very shortly, here’s that link as well:

Guidelines for Reopening Texas Dental Practices

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.

Should dental hygienists give shots?

March 15, 2017 By Trish Walraven 13 Comments

When people talk about what they hate most about going to the dentist, they’re usually talking about the needle. I mean, who in their right mind would ever consent to allowing another person to give a shot in a place that has as many nerve endings as our tongues, lips and cheeks? Shots in the mouth are pretty dang scary. And when you’re trying to calm down and prepare yourself for an injection, it’s almost worse than trying to relax for the air-burst thingy they do at the optometrist’s office when you’re getting your eye pressure checked.

And yet, anyone who has had significant dental treatment performed has allowed someone to inject their mouth with a needle, right? We’ve all accepted the fact that shots are so much better than the actual thing that we hate about going to the dentist.

Pain. Pain is what we really hate.

And shots? They make pain go bye-bye. No shot? You’re all-knowing (in a very bad way) about every little thing that is getting fixed in your mouth.

But you already realize this unpleasant truth. What you might not know is that there’s a stink in Texas right now about who can give shots at the dentist’s office and who can’t. Here’s a little backstory: Dentists go to college for 6-8 years to learn all the things they need to do in order to be dentists. Dental hygienists are in college for 2-4 years to learn everything they need to learn in order to be dental hygienists. In states that allow dental hygienists to give shots, their anesthesia education follows the same curriculum as dentists. These states also test dentists and hygienists to make sure that they are qualified to give shots before granting their licenses.

In Texas and five other states, this is not true. A dental hygienist’s education in regards to anesthetic delivery is considered inferior, and therefore, allowing hygienists to stick a needle in a patient’s mouth allegedly places the public in unnecessary danger.

On this map, you’ll see red states, with years next to their abbreviations. These are the states that allow hygienists to give shots, along with the dates when administration and licensing first became available. [edit: See image at update at the bottom of this article – this was amended to 47 states in 2023]

Do I think that Texas should allow dental hygienists to give shots just because “everyone else is doing it?” No. We tried being our own country once, and if we still were our own country we wouldn’t care one tiddly bit what was going on in the US.

The reason that Texas should allow dental hygienists to give shots is simple:

We are tired of hurting people.

The alternative is to ask the dentists we work with to leave a hole in their schedule so they can come give a shot for us. And come anesthetize again if the first time didn’t work. And again if our patient is still in pain.

Here in Texas, hygienists learn to say “I’m Sorry” a lot to our patients, instead of continuing to interrupt our dentists.

Thankfully, most of our patients don’t need shots. Those who come regularly have healthy mouths and their visits with the dental hygienist are preventive in nature, comfortable, maybe even relaxing. But take a person who has been scared to go to the dentist for a while and they’ve noticed that their gums bleed when they brush. There are sores in their gums, and guess what? The treatment it takes to heal up those sores can hurt! Hygienists in all states are highly trained to provide this deeper therapy – it’s what we “really” do. And if there are obstacles to providing this treatment painlessly, well, it’s either not going to be painless, or else the treatment won’t be as thorough as it would have been if it would have been if the patient had gotten completely numb.

Last week’s hearing of the Texas Senate Committee on Health and Human services highlighted the stances of those both in favor and against granting dental hygienists the permission to deliver local anesthesia, in other words “give shots.” The original video was 2 1/2 hours – I’ve shortened it down to a little under 40 minutes of testimony only about this bill, edited out all the procedural or repetitive bits, and left the juiciest parts behind.

Full video of the archived meeting: http://tlcsenate.granicus.com/MediaPlayer.php?view_id=42&clip_id=11813

Here are my bullet points, yes… •Bullet •Points for this committee meeting:

• The map handed out in the chamber is the same one you see in this article (feel free to scroll up and follow along).

• The bill is permissive, not mandatory. If a dentist does not want to allow a hygienist in their office to give shots, they can’t. Furthermore, dentists must be present in the office for hygienists to administer anesthetics.

• No evidence of harm is presented in any testimony. Scroll to 18:45 where you’ll see Dr. Scott Dowell testifying for the Texas Society of Periodontists against this bill. His admission of the relative danger of local anesthesia is…interesting.

• The Texas Dental Association states that they opposed to this bill due to patient safety because they feel that it lowers the education standard and it’s only about expanding dental hygienist’s scope of practice, possibly to open the door to independent practice by hygienists.

• Dr. Matthew Roberts, who represented the Texas Dental Association, seemed surprised to learn that physicians are legally allowed to delegate the duty of administering anesthesia shots to even medical assistants in their practice when this is brought up in the meeting.

• There are 9000 members of the Texas Dental Association, but in a poll, 53% of the members were actually in favor of hygienists giving shots.

• The amount of training dentists receive to legally put patients “to sleep” is less than the training hygienists receive in order to be legal to give shots.

If you’re not convinced by this video, then you didn’t actually watch it (my opinion, sheesh!). But if you did watch it and still feel like hygienists are unqualified to give shots, your voice is very important to us right now. Maybe there are more problems with hygienists using needles, maybe there are negative reports that haven’t been correlated properly. Do you have concerns? Post them here in the comments below. I’m serious – if there is a compelling reason that is being hidden from the public and even from hygienists, we all deserve to know the truth.

At this point, though, if the day ever comes when I’ll be able to give my patients shots, it will be like someone trusted me with the most delicate equipment available in the Compassion Toolbox. It is a precious gift to be able to deliver painless dental care, and for those in the caring business (which most of medicine is, if you think about it) sometimes it’s the best gift we can give to others.

Yuck, ick, too late, the mush landed. Bottom line? Please don’t hate me if I ever get to stick you with a needle.

Trish Walraven RDH, BSDH is a dental hygienist who lives in the suburbs of Dallas/Fort Worth. She longs for the day when she can drop a couple grand of her own money and leave her family to take a week-long college course, just so she can sit for an anxiety-provoking board exam that will grant her the license to poke a shot in places that no one wants poked. Goals, man. Goals.

UPDATE 4/5/2017: The April newsletter from the TSBDE states that SB 430, which would authorize dental hygienists to administer local anesthetic was heard in the Senate Health and Human Services Committee on March 8, 2017. The committee considered testimony both for and against the legislation. The bill was voted out of the Health and Human Services Committee on April 5, 2017 with some changes. The change is that only infiltration administration would be permitted. The bill is now waiting to be scheduled to be heard by the full Senate.

UPDATE 5/25/2023:

It’s been six years since the original article above was posted; however, today I received the following information:

“After almost a year of collaboration between TDHA [Texas Dental Hygienists’ Association] and TDA [Texas Dental Association], legislation passed today through the Texas Senate that would allow Texas dental hygienists to administer local infiltration anesthesia.

The last step is for Governor Abbott to approve and sign the bill which would then become law. After the legislation is signed by the Governor, the Texas State Board of Dental Examiners will be tasked to write specific rules and educational requirements that will align with the intent of the legislation. This is a lengthy process that can take up to a year. The rules will then need final approval from the Governor’s Office.

Please note – this legislation allows dental hygienists to administer local anesthesia under the direct supervision of a dentist via infiltration only to patients who are over the age of 18.”

Here’s the thing: this was also the biggest bone of contention even 30 years ago for the majority of Texas dental hygienists. For over 30 years we have been arguing for this option! That’s pretty much the scope of an entire career. Enough said – all you 50+ year olds who’ve been waiting for this day? See y’all back in college soon!

How does Ebola change dental infection control?

October 12, 2014 By Trish Walraven 14 Comments

At first I wasn’t worried. I was probably like you, thinking this was halfway around the world, and that it was their problem.

And then… it wasn’t just their problem. It became mine, too.

Now, I’m no infectious disease expert. I’m simply a dental hygienist who lives in the Dallas area, the center of the recent Ebola panic. And we should be terrified of what Ebola does to its victims. It’s scary, it’s creepy, and it’s lethal, in a super-speedy, no-time-to-say-goodbye-to-your-loved-ones zombie apocalypse way that you have probably freaked yourself out about enough already.

Instead, let’s look at how this affects us in dentistry. The question that is coming up most often between dental healthcare providers right now is “what are we supposed to do?”

The CDC offered the following Q&A reply to an American Dental Association inquiry this past September:

“Can I provide dental services to someone who has recently been in West Africa?

“CDC works with partners at ports of entry into the United States to help prevent infectious diseases, like Ebola, from being introduced and spread in the United States.

“A person infected with Ebola is not contagious until symptoms appear. Signs and symptoms of Ebola include fever (greater than 38.6°C or 101.5°F) and severe headache, muscle pain, vomiting, diarrhea, stomach pain or unexplained bleeding or bruising.

“The virus is spread through direct contact [CDC emphasis] (through broken skin or mucous membranes) with blood and body fluids (urine, feces, saliva, vomit and semen) of a person who is sick with Ebola, or with objects (like needles) that have been contaminated with the virus. Ebola is not spread through the air or by water or, in general, by food.

“Dental providers should continue to follow standard infection control procedures.”

And from the ADA website:

There is no risk of transmission of Ebola from asymptomatic infected patients. According to the ADA Division of Science and Professional Affairs, dental professionals are advised to take a medical history, including a travel history from any person with symptoms in which a viral infection is suspected. If Ebola is suspected, dental professionals may need to protect themselves with physical barriers (gowns, masks, face protection, and gloves), and contact their state or local health department.

According to the CDC, “Providers should consider Ebola in patients who develop a fever greater than 101.5 degrees Fahrenheit, severe headache, muscle pain, diarrhea, vomiting, stomach pain, or unexplained bruising or bleeding 21 days after traveling from Guinea, Liberia, Nigeria, or Sierra Leone.” Standard precautions should be used on all patients as a matter of routine.

So, did you actually READ any of the statements above? Basically, it’s saying to all dentists, hygienists, and dental assistants, move along, nothing here to see, business as usual as long as no one has been to Africa. Okay, so that used to be true.

The problem is that even though proper protocols are in place, that mean one of two things is happening to cause Ebola to infect people in the US:

1) We are not following Universal Precautions properly, or

2) Universal Precautions as we know them are inadequate.

Case in point. Today a health care worker was accused of breaching the PPE protocol because she has been now diagnosed with Ebola. The second one in our country. It could have been the other guy; you know, the deputy who went into the Ebola apartment without a Hazmat suit that ended up getting quarantined at an urgent care center up in Frisco?

Yeah, it got pretty crazy in our town last week, because he lives here. In fact, his daughter goes to school with our son. Thankfully our town responded very amazingly to him and his family at the time of crisis and we were all very relieved that it ended up being a false alarm.

So, if the problem is that we’re not following Universal Precautions, maybe then, we all need a little more muscle memory in our procedures so that we’re already doing our best if this stuff ever does become epidemic.

I know that I’m not always faithful about taking my loupes, mask, and gloves off the perfect way, every time, but you better believe that I’m going to be practicing this with chocolate syrup on my gloves the next time I’m in the office.

Seriously, maybe it’s time for your team to refresh themselves on how to properly remove their personal protective equipment.

Come on, who wouldn’t want to be in a room full of women (as is the case with most dental teams), passing around a bottle of Hershey’s, adding a little drizzle onto each person’s gloved hands, watching the syrup slick between their latex or nitriled-up fingers, then having them do a striptease routine in front of each other to see if they contaminate themselves?

Believe it or not, this is something that the OSHA recommends. If you’d prefer the CDC’s boring version to practice, though, you can print this PDF out instead:

As far as the other scenario? The one where the infectiousness of Ebola is far, far worse than what our sacred Universal Precautions can handle? What DO you say about that? Hey, nice knowing you, I’m changing professions now, love ya, see ya around but not here, bye?

Let’s hope then – for everyone’s sake – that we have all just been sucking at taking our gloves and masks off.

A blogger since 1997, Trish Walraven, RDH, BSDH is a practicing dental hygienist and marketing manager for an indie dental software development company. She’s now concerned about the effectiveness of the mask she’s currently using in her office but continues to put it on the list of low priorities until the zombies actually come crashing into her operatory.

UPDATE – October 16, 2014:

(Now THIS is more like it!)
ADA American Dental Association
Guidance to Dental Professionals on the Ebola Virus

A person infected with Ebola is not considered contagious until symptoms appear. Due to the virulent nature of the disease, it is highly unlikely that someone with Ebola symptoms will seek dental care when they are severely ill. However, according to the Centers for Disease Control and Prevention and the ADA Division of Science, dental professionals are advised to take a medical history, including a travel history from their patients with symptoms in which a viral infection is suspected.

Any person within 21 days of returning from the West African countries Liberia, Sierra Leone and Guinea may be at risk of having contacted persons infected with Ebola and may not exhibit symptoms. If this is the case, dental professionals are advised to delay routine dental care of the patient until 21 days have elapsed from their trip. Palliative care for serious oral health conditions, dental infections and pain can be provided if necessary after consulting with the patient’s physician and conforming to standard precautions and physical barriers.

You are advised not to treat dental patients if they have the signs and symptoms for Ebola. If a patient is feeling feverish and their travel history indicates they may be at risk of Ebola, dental professionals and staff in contact with the patient should:

• protect themselves by using standard precautions with physical barriers (gowns, masks, face protection, and gloves)
• immediately call 911 on behalf of the patient
• notify the appropriate state or local health department authorities
• ask the health department to provide you and your staff with the most up-to-date guidance on removing and disposing of potentially contaminated materials and equipment, including the physical barriers.

The Ebola virus is spread through direct contact (through broken skin or mucous membranes) with blood and body fluids (urine, feces, saliva, vomit and semen) of a person who is sick with Ebola, or with objects (like needles) that have been contaminated with the virus. Ebola is not spread through the air or by water or, in general, by food. Again, there is no reported risk of transmission of Ebola from asymptomatic infected patients.

Abundant Safety Precautions and Screening

Anonymously Mummified Clinicians

Animal-Sized Airflow Management

Low Aerosol Dental Treatment

Isolation and Solitary Confinement

References:

We are tired of hurting people.

UPDATE 5/25/2023:

UPDATE – October 16, 2014:

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