Tuesday, April 7, 2020

Decontamination and Reuse of Filtering Facepiece Respirators

In the tough times we are currently all facing, drastic measures and methods are necessary to ensure that we keep everyone safe and that especially applies to those on the front lines as primary healthcare providers.  As has become commonly known, there is a critical shortage of N-95 masks currently.  Below are recommendations from the CDC on how to sterilize & reuse them.  The complete page with all information can be found by following this link.

Disposable filtering facepiece respirators (FFRs) are not approved for routine decontamination and reuse as standard of care. However, FFR decontamination and reuse may need to be considered as a crisis capacity strategy to ensure continued availability. Based on the limited research available, ultraviolet germicidal irradiation, vaporous hydrogen peroxide, and moist heat showed the most promise as potential methods to decontaminate FFRs. This document summarizes research about decontamination of FFRs before reuse

Reusing disposable filtering facepiece respirators (FFRs) has been suggested as a contingency capacity strategy to conserve available supplies for healthcare environments during a pandemic. Strategies for FFR extended use and reuse (without decontamination of the respirator) are currently available from CDC’s National Institute for Occupational Safety and Health (NIOSH).

The surfaces of an FFR may become contaminated while filtering the inhalation air of the wearer during exposures to pathogen-laden aerosols. The pathogens on the filter materials of the FFR may be transferred to the wearer upon contact with the FFR during activities such as adjusting the FFR, improper doffing of the FFR, or when performing a user-seal check when redoffing a previously worn FFR. A study evaluating the persistence of SARS-CoV-2 (the virus that causes COVID-19) on plastic, stainless steel, and carboard surfaces showed that the virus is able to survive for up to 72-hours [1]. One strategy to mitigate the contact transfer of pathogens from the FFR to the wearer during reuse is to issue five respirators to each healthcare worker who may care for patients with suspected or confirmed COVID-19. The healthcare worker will wear one respirator each day and store it in a breathable paper bag at the end of each shift. The order of FFR use should be repeated with a minimum of five days between each FFR use. This will result in each worker requiring a minimum of five FFRs, providing that they put on, take off, care for them, and store them properly each day. Healthcare workers should treat the FFRs as though they are still contaminated and follow the precautions outlined in our reuse recommendations. If supplies are even more constrained and five respirators are not available for each worker who needs them, FFR decontamination may be necessary.

Decontamination and subsequent reuse of FFRs should only be practiced as a crisis capacity strategy. At present, FFRs are considered one time use and there are no manufacturer authorized methods for FFR decontamination prior to reuse. On March 28, 2020, FDA issued an Emergency Use Authorization (EUA) permitting the Battelle Decontamination Systemexternal icon at Battelle Memorial Institute to be authorized for use in decontaminating “compatible N95 respirators.” The FDA websiteexternal icon should be checked to determine if other EUAs have been issued since the posting of this crisis capacity strategy guidance. Only respirator manufacturers can reliably provide guidance on how to decontaminate their specific models of FFRs. In absence of manufacturer’s recommendations, third parties may also provide guidance or procedures on how to decontaminate respirators without impacting respirator performance. Decontamination might cause poorer fit, filtration efficiency, and breathability of disposable FFRs as a result of changes to the filtering material, straps, nose bridge material, or strap attachments of the FFR. CDC and NIOSH do not recommend that FFRs be decontaminated and then reused as standard care. This practice would be inconsistent with their approved use, but we understand in times of crisis, this option may need to be considered when FFR shortages exist.

An effective FFR decontamination method should reduce the pathogen burden, maintain the function of the FFR, and present no residual chemical hazard. The filter media in NIOSH-approved respirators varies by manufacturer. The ability of the respirator filter media to withstand cleaning and disinfection are not NIOSH performance requirements. The NIOSH’s National Personal Protective Technology Laboratory (NPPTL) and other researchers have investigated the impact of various decontamination methods on filtration efficiency, facepiece fit of FFRs, and the ability to reduce viable virus or bacteria on the FFRs. This research is summarized below.

Crisis Standards of Care Decontamination Recommendations
Because ultraviolet germicidal irradiation (UVGI), vaporous hydrogen peroxide (VHP), and moist heat showed the most promise as potential methods to decontaminate FFRs, researchers, decontamination companies, healthcare systems, or individual hospitals should focus current efforts on these technologies. Specifically, the effectiveness of using these methods should be explored further with specific FFR models based on the manufacturers’ support to better understand the impact on the respirator performance, including filtration and fit. The respirator manufacturer should be consulted about the impact of the method on their respirators prior to considering the use of any method.

When information from the manufacturer or a third-party is available showing that respirators can be successfully decontaminated without impacting respirator performance, then FFRs decontaminated following those recommendations can be worn for any patient care activities.
In the absence of guidance or when information is available that a respirator cannot be decontaminated without negatively impacting the performance, respirators may still be decontaminated. However, given the uncertainties on the impact of decontamination on respirator performance, these FFRs should not be worn by HCPs when performing or present for an aerosol-generating procedure.

No current data exists supporting the effectiveness of these decontamination methods specifically against SARS-CoV-2 on an FFR. Other pathogens may also be present on FFRs and there is only limited data available for other pathogens. Further work is needed to assure SARS-CoV-2 and other pathogens are inactivated. Therefore, even after decontamination, these FFRs should be handled

HCPs should take the following precautionary measures prior to using a decontaminated FFR:
  • Clean hands with soap and water or an alcohol-based hand sanitizer before and after touching or adjusting the FFR.
  • Avoid touching the inside of the FFR.
  • Use a pair of clean (non-sterile) gloves when donning and performing a user seal check.
  • Visually inspect the FFR to determine if its integrity has been compromised.
  • Check that components such as the straps, nose bridge, and nose foam material did not degrade, which can affect the quality of the fit, and seal.
  • If the integrity of any part of the FFR is compromised, or if a successful user seal check cannot be performed, discard the FFR and try another FFR.
  • Users should perform a user seal check immediately after they don each FFR and should not use an FFR on which they cannot perform a successful user seal check.

Saturday, April 4, 2020

Fight to Overturn the Department of Treasury and SBA Interim Guidance on the SBA 7(a) PPP Loan and EIDL Loan

As if the pandemic weren't bad enough, now we've got the "bureaucracy-demic".  It seems that after all the assurances that the federal government would help small businesses, they are now trying to make sure that doesn't happen.  Dentists need to read this and follow this link at the bottom to make their voices heard. 

Fight to Overturn the Department of Treasury and SBA
Interim Guidance on the SBA 7(a) PPP Loan and EIDL Loan
Hello, Fellow Dentists:

Since the COVID-19 pandemic began, dentists and dental offices across the country have been feeling the strain. We have seen the federal government issue numerous regulations and guidance. Along the way, we have told you that we need to be prepared to deal with unforeseen government edicts—particularly with respect to regulations and guidance—that do not consider the impact they may have on many sectors of our economy and our profession.

Today, we are faced with such a circumstance.  

The U.S. Small Business Administration has just issued interim guidance pertaining to the SBA Economic Injury Disaster Loan (EIDL) and 7(a) Paycheck Protection Program. The guidance stipulates, in effect, that small businesses must choose between the two loans; small businesses can’t receive both loans unless a qualified business receives their EIDL loan money on or before April 3.  

The guidance clearly contradicts the law (CARES Act) as written and as interpreted by the very committees of jurisdiction who drafted the legislation. The committee summaries and Q&A documents make it clear that qualified small businesses can apply for both the EIDL and Paycheck Protection Program loans, without specific date restrictions.

If this interim guidance stands, it would pose great harm to the vast majority of our dentist owners and other small businesses who have applied for but have not received any EIDL loan money by April 3.

The Grassroots Action Alert that we are asking you to respond to today is being sent to U.S. Department of Treasury Secretary Mnuchin and U.S. Small Business Administration Administrator Carranza, and much like the letter the ADA sent to them last night, we are “strongly recommending that the SBA work with Treasury to change the interim rule to clearly indicate that entities can apply for both loans and that they are still eligible to apply for both, even if EIDL loan funds are received after April 3. This would ensure that SBA and Treasury are following the congressional intent of the CARES Act…”

You should know that when you send your action alert to Secretary Mnuchin and Administrator Carranza, a copy of the alert will go to your Representative in the House as well as your two Senators. Your members of Congress will also know of the harmful effects of this interim guidance to your practice, your patients and the public.

This is interim guidance that we must oppose, and oppose with the same intensity that we brought to bear when we sent nearly 400,000 emails to Capitol Hill from more than 120,000 dentists regarding final passage of the CARES Act.

Please click on the link and let Secretary Mnuchin and Administrator Carranza know your opposition to this SBA interim guidance.

Thank you for what you are doing for your practice, your patients and dentistry!

Stay well,

Chad P. Gehani, DDS

And the Pandemic Goes On...


This whole Covid-19 thing has put pretty much everything into a tizzy in my life (not sure what a “tizzy” actually is, but my grandma used the word a lot and I really like it).  Like most dental offices, we are only seeing emergencies until at least May 1 and probably longer thereafter, but at this point no one really knows...

I have several unique perspectives on this whole pandemic.  I’ve got the healthcare view and that means I’ve got to protect my fellow man while being as careful as possible not to spread this thing.  I’ve got the business owner view and that means I’m dealing with furloughed employees that I’m worried about.  I’m a doctor with a recurring schedule of patient care and that means I worry about my patients even if it has nothing to do with dentistry.  My patients are people I care for but also care *about* and I want them all to be safe and well

The other perspective I have is due to the fact that I live in Kansas and practice in Missouri.  The state of Kansas is on a governor ordered “shelter at home” while Missouri is not.  Because of that I am seeing the virus spread more rapidly just to the east of my home.  It also means that the virus is more prolific in the area where my business is located.  In the big picture will that make a difference?  At this point everything is a guess, however I do know that keeping away from others is the best way to prevent spread of the infection.

Yesterday I did a virtual presentation on Chartless Dentistry for the Western Regional Dental Experience.  I’ve done a fair number of webinars in my career, but never one that was 3 hours long.  I have to confess, that it’s tough to talk to your computer screen for that long when the only live person you can see is you in a small thumbnail on the screen.  However, the event came off really well.  There were *a lot* of people logged in and I got some good immediate feedback.  There were a couple of tech glitches, but they were overcome.  I think this very well might be the CE platform of the not too distant future.  We’ve all seen how popular Zoom has become and with the proliferation of broadband connections, this will only get better.

As a final note to this post, hats off to whoever created the hash tag #FlattenTheCurve!  It sums up exactly what we all need to do right now.  We are living in perhaps the most uncharted time in recent memory.  We’ll get through this, but it’s going to take some time.

I’ll continue to post at pace that is stranger than normal.  You may see one post a day like always, or you may see 3 a day.  In times like these, nothing is a sure thing.

Stay safe and be well! 

Friday, April 3, 2020

ADA Extends Closure Recommendation Through April 30th

In a statement issued April 1, the ADA issued an interim recommendation that “dentists keep their offices closed to all but urgent and emergency procedures until April 30 at the earliest.”

The ADA’s original recommendation, issued March 16, was set to expire on April 6.

The interim recommendation is in keeping with the recent U.S. Centers for Disease Control and Prevention’s recommendation to perform only emergency or urgent dental care.

According to the statement, “The ADA also recognizes that existing and future local or state government mandates supersede ADA recommendations. In addition, state dental associations may best understand local challenges being faced and make recommendations appropriate to members in their areas.”

In addition, “The ADA believes individual dentists should exercise professional judgment and carefully consider the risks outlined in the ADA’s interim guidance and weigh those risks against any possible benefit to the patient, the practice employees, the community at large, and the practitioner. Critically important is the availability of appropriate personal protective equipment (PPE) to minimize any risk of transmission during emergency and urgent care. Due to the proximity of individuals during dental procedures, and the generation of aerosols, dentists, staff and patients are at high risk of transmission.”

The statement concludes, “The PPE required to reduce the risk of transmission during dental treatment to its lowest levels — as noted in algorithm No. 3 of the ADA Interim Guidance for Management of Emergency and Urgent Dental Care — are scarce. Asymptomatic patients cannot be assumed to be COVID-19 free. As of March 31, point of care tests exist, but are extremely difficult to obtain. Unless point of care tests are readily available to the dental practice, no one can be assured that they are treating a non-infected individual. The safety of their patients, staff and themselves should be foremost when dentists exercise their professional judgment, and information regarding the relative risks is available from the ADA, via the Interim Guidance, to assist in making those decisions.”

Monday, March 30, 2020

A Nifty DIY Respirator that has the Potential to Provide Better Filtration than N-95



One of the things I truly love about dentistry is the passion that many of us feel for the profession.  This morning's post is going to go right along with that sentiment.  As we all know, the big news story of the last month has been the novel Corona  Virus with can lead to Covid-19.

The virus originated in the province of Wuhan, China and then rapidly spread across borders, demonstrating how amazingly contagious the virus is.  As it initially began to infect people in China, doctors, public health officials, and epidemiologists tried to get a handle on how the virus managed to spread so rapidly and efficiently.

A virus has always been trickier to deal with than a bacterium for a variety of reasons.  We won't get into all of those here today, however I would like to detail ONE trait that a lot of folks  outside  of medical realms are unaware of.  A virus (or viral particle) is *tiny* compared to a true bacteria.  Due to their size, they can frequently get through filtration mediums that stop other infectious agents in their tracks.

In many practices of medicine, dentistry included, a surgical mask is part of the everyday PPE (Personal Protective Equipment) that practitioners wear.  The surgical mask is a 2 way street.  It not only protects the healthcare worker from receiving infectious particles from the patient, but it also prevents the patient from receiving infectious particles from the healthcare worker.

It's also the same story for gloves.  Studies that had been done back in the times when dental professionals worked without gloves found that bacteria from the mouths of patients seen on Monday could be cultured from under the fingernails of workers on Friday afternoon.  Basically that meant that every patient seen for a week left their bacteria on the dentist's hands and therefore into the patient's mouth.  Scary right?

But for this discussion we're going to concentrate of the mask.  Recent studies of the Novel Corona Virus show it to be somewhere between 140 nanometers and 60 nanometers in size while the average size of bacteria is around 300 nanometers.  Surgical masks usually filter to about 100 nanometers while N-95 respirators filter to 30 nanometers.

Surgical masks are designed to cover the moth and nose loosely but are not sized for individual fit.  However, N-95 Respirators are designed to fit the wearer closely.

As the Covid-19 pandemic has progressed we, in healthcare, have seen an incredible shortage of N-95 masks as there is a scramble to protect healthcare workers from becoming infected and potentially passing the virus along to other patients and healthcare providers.

Now one of my pet peeves, as many of you know, is that when someone asks why we do something a certain way, the answer is "because we've always done it that way."  That's just a plain lousy answer.  So the question I've been asking the past week or 2 is "why do we always buy masks from distributors" and the answer is... you guessed it.

Then I came across a small website called www.firedbycorona.com  This website was put together by Dr. Mark Causey who is an orthodontist in Georgia.  Dr. Causey is a forward thinking guy and uses a 3D printer in his office.  His idea was, rather than buy N-95 masks and then throw them away, why not print a N-95 framework that you could theoretically use for years and simply replace the filtration when it was no longer working.  Genius!  Dr. Causey even designed the framework, saved it in an stl file, and made it available *for free* on his website.

His thought process is that if everyone that has a 3D printer started to produce these frameworks, we might very well cut the N-95 mask shortage.  His website goes through the entire process of creating a N-95 mask from a printed frame and readily available HEPA filters.

Since discovering this website, I've been printing these mask substructures pretty much non-stop on my Ender-3 printer in my home.

We are now creating masks that help prevent the spread of the Novel Corona Virus while also keeping masks out of the landfill.

I'll be doing more posts on this fascinating subject in the next few days.  I'm proud of Dr. Causey for his hard work and outside the box thinking.

Friday, March 27, 2020

More Information from the Academy of General Dentistry

AGD Special Alert
Special AGD Update: COVID-19 Relief and Resources
Dear Member,
I hope this note finds you safe. These are trying times for us as general dentists but also as family and community members. Our profession and the world around us are changing so rapidly. I encourage you to continue to connect with your AGD colleagues. We are all in this together, and we will get through this together. 

Today I want to remind you that AGD remains available to support you during this tumultuous time. Here are a few updates:

Economic Relief Legislation
The economic stimulus legislation being finalized in Congress will serve as a lifeline for most dental practices. Our team has broken down some highlights to help you understand how to access the financial relief opportunities. We are also monitoring the U.S. Small Business Administration for loan opportunities that might be beneficial to members. We ask that you watch for AGD requests to communicate with legislators to ensure that the needs of general dentists are not forgotten. 
Center for Disease Control Guidelines Updated
The CDC has released Interim Infection Prevention and Control Guidance for Dental Settings during COVID-19 Response. Check out the update.
AGD Webinar Series: Staying Connected During COVID-19 
We are launching a free webinar series to help answer questions about how COVID-19 is impacting general dentists. All programs are scheduled from 7:30 to 9 p.m. CDT. The first three in the series are below:
Don't forget the Tuesday, March 31 free webinar: Patients Judge Your Practice by Your Online Reputation. Watch for additional webinars in the series.  Many other events are being added or made available free of charge. Visit our website to see the full list of offerings.

We are preparing for any influence this pandemic may have on AGD's upcoming meetings, including our scientific session scheduled for July 15–18 in Las Vegas. We want you to assure you that if AGD2020 is cancelled as a result of COVID-19, all registered attendees will receive a full refund, including conference registration and course fees.

Help for your practice now
Addressing your business operations and staying in front of your patients and communities are as important as ever. We have contacted several of AGDs Exclusive Benefit providers to ask them to help you now.
  • Stay in Touch with Your Patients: AGD's new Exclusive Benefit provider Optio Publishing has generously offered to provide all AGD Members with free social media content to help you communicate with your patients about COVID-19. Check out the free content. Watch for more news about other offers from this new Exclusive Benefits provider.
  • Cash Flow Help: A new Exclusive Benefit provider, U.S. Bank is now offering temporarily reduced pricing on its Quick Loan and Cash Flow Manager products. For more information, contact Jeramie Eimers or 651.681.7371. Please note that they do not cover all states.
  • Payment Deferrals: Hagan Insurance Group employees are available to answer coverage questions. If these hard times are causing issues with paying your insurance premiums please do not hesitate to contact their office at 877.280.6487 to see what payment options may be available to help you through this difficult time.  
  • Keep Your Dental Team Sharp: All-Star Dental Academy is making its Survival Kit: Resources for Dentists including a video on "Training While Your Office is Closed" available to all AGD members free of charge. It outlines issues to address during this crisis and steps to ensure that your practice can continue to grow.
PPE Supplies
AGD is encouraging members to donate surplus personal protection equipment (PPE) to your local public health offices or first responders. Please retain the supplies you need to cover emergencies and to re-open your office when the time comes, but also consider how you can support the safety of healthcare professions on the frontlines. AGD has been reminding the public to avoid hospital emergency rooms if they have a dental need during this time. We want to reduce the burden those dental visits would have on sites that are focusing on the diagnosis and treatment of COVID-19 patients.

Our website, agd.org, has special COVID-19 updates. Events, news, analysis and other links to helpful resources are being added regularly, so please check in periodically for updates.

On behalf of the AGD family, I want you to know that we stand ready to help you through this unprecedented time. Please let us know how we can help.

Connie L. White, DDS, FAGD
President, Academy of General Dentistry

Wednesday, March 25, 2020

Academy of General Dentistry says Let's Work Together and Get Through This

Here is a letter I received yesterday via email.  I've known Dr. Connie White for over 30 years.  She is a dedicated professional with a heart of gold.  We couldn't ask for better person at the helm of the Academy right now.  Read on to see what Dr. White has to say...

Dear Member,

I know you are facing an unimaginable level of stress and anxiety because of COVID-19. Despite the uncertainty for the future, I am optimistic. AGD is here for you.

We continue to post information about the coronavirus to www.agd.org/coronavirus. This week we will add a new section on the AGD website that will direct you to resources, tools and options to assist you, our AGD family members, during closures and once operations resume. In the meantime, I wanted to list some of the other ways we are working to assist you.

No-Cost Webinars and Online Learning: We know our members want CE that will help them manage their financial and staffing needs during this crisis, as well as provide guidance on how to plan for the future. Our Education team is currently developing several webinars that address these needs, and we plan to roll these out as soon as possible.

We are also waiving the fees for upcoming CE, including the tonight's webinar "The Science of Sleep and the Importance and Management of Oral Appliance Therapy." The March 31 webinar "Patients Judge Your Practice by Your Online Reputation" is a free course sponsored by Henry Schein One. 

The AGD Online Learning Center continues to provide a wealth of educational content, and we are working with the Dental Education Council to expand free offerings. We will provide updates as those details become available.

Financial Relief for General Dentists: AGD sent a letter to Congress strongly recommending that general dentists be compensated in the amount of $500 million to make up for lost patients. Further, the AGD Government Relations and Dental Practice teams are reviewing the economic stimulus package and other policies that are in place or being discussed that could help our members. We are distributing information to members on ways they can advocate for the profession by contacting federal legislators. (See how New Jersey AGD members are working locally.) We will continue to report on these details in the coming days and weeks. 

Other Support Options for You: We have already arranged with an AGD banking partner to offer reduced interest rate loans. The ability to check it out and apply online should be available in the coming days. 

Please contact our Membership Services team if we can be of assistance with dues payments. We will work with you to ensure you are able to continue benefiting from your AGD membership. 

We are also working directly with our Exclusive Benefit providers and corporate sponsors to help our AGD family during this time of need. 

Don't Isolate Yourself: We are being asked to distance ourselves socially, but this isn't a time to isolate from your colleagues and the profession. To help you connect with other general dentists about ways they are navigating this new territory, AGD has created online communities so that you can share information and connect with other members. We have created a new one devoted to allowing members to share specifically about their experiences and suggestions to others in the AGD family about COVAD-19. To sign up for these communities, please email AGDConnect@agd.org

We fully expect our profession to rebound. I've heard remarkable stories about members helping members, colleagues, students, families and communities. Now more than ever, we must remain strong to support each other. 

Please keep watching for updates and let us know if you have additional needs, requests or suggestions on how we can serve you.

In the meantime, stay safe and healthy.


Connie L. White, DDS, FAGD
President, Academy of General Dentistry

Tuesday, March 24, 2020

Shelter at Home... Day One


I’m posting this from my office where I’m still open on a limited basis for emergencies.  This is day one of the greater Kansas City area “Shelter at Home” directive.  As a healthcare provider I’m exempt from the restriction as dentistry is considered an “essential” business.

Traffic on the way to the office was light… as in really light.  It seems that most people are following the guidelines.

Amazingly for the office, we have seen more emergencies than normal.  However, with that being said, we will be going to a much more abbreviated schedule next week.  While we are seeing more emergencies than normal, that certainly does not mean we’re dealing with a full schedule.  It’s been interesting the last few days.  Yesterday I was contacted via Facebook Messenger from a nurse on the east coast who works in the ER.  She was having trouble finding dental offices that were open and she was seeing quite a few dental emergencies that were creating backlogs in the ER.

I would strongly urge offices that are completely shut down to consider at least a limited schedule to help those in need.

More news as things progress...

Monday, March 23, 2020

News from the Drug Enforcement Administration...

DEA COVID-19 Information

COVID-19 Virus
Dear Registrant,
On March 16, 2020, the DEA published a COVID-19 Information Page on the Diversion Control Divisions Web Site. This page contains important guidance concerning COVID-19 and the national drug supply, electronic prescribing of controlled substances, telemedicine, medicated assisted treatment, and other important federal and state information. This site will be updated frequently as new information and guidance is issued. Please check back frequently for further information.
Please continue to direct all policy questions concerning COVID-19 to the Policy email box at Natural.Disaster@usdoj.gov

DEA Call Center

Effective March 23, 2020, the DEA Call Center has temporarily suspended phone operations due to COVD-19 health epidemic. Assistance will only be available through email at DEA.Registration.Help@usdoj.gov. The DEA has a large number of personnel answering these emails as quickly as possible.

The Day Before the Lockdown...

Welcome to "The Final Countdown" in the Greater Kansas City Area.  For those of you who are unaware, the area where I live and practice is going on a "Shelter at Home" order starting at midnight tonight.  When the sun rises Tuesday the 24th almost everyone here will be expected to be at home unless making trips for necessary items or services.

Only certain businesses will be open and employees of those businesses are cleared to go to work.  Fortunately, healthcare is considered necessary.  That means I won't be totally stuck at home, although I'll be at the office handling emergencies.

I'm going to be blogging on a less structured schedule going forward.  I normally try and post Monday thru Thursday but there may be multiple posts a day and more than usual simply because we're all in a situation we've never been in before.

I'm also going to be tinkering with my tech more now that I have fewer demands on my time since patient time will be less and my travel schedule is now non-existent.

One thing you might look into, if you are looking for some CE to fill your time, the Western Regional Dental Experience is going virtual this year.  I've got a course I'm giving virtually on April 2nd so feel free to sign up.  I'd love to be able to help my peers during this time when we're all going to be trying to find ways to improve our skills while we are idle.

More tomorrow as the shutdown continues..

Sunday, March 22, 2020

ADA Releases Emergency Procedure Guidelines

What Constitutes a Dental Emergency?
The ADA has released the following guidelines.  They are reposted here to help with the current crisis.  Any questions should be answered by going to this web address.

The ADA recognizes that state governments and state dental associations may be best positioned to recommend to the dentists in their regions the amount of time to keep their offices closed to all but emergency care. This is fluid situation and those closest to the issue may best understand the local challenges being faced.


This guidance may change as the COVID-19 pandemic progresses. Dentists should use their professional judgment in determining a patient’s need for urgent or emergency care.
Dental emergencies are potentially life threatening and require immediate treatment to stop ongoing tissue bleeding, alleviate severe pain or infection, and include:
  • Uncontrolled bleeding
  • Cellulitis or a diffuse soft tissue bacterial infection with intra-oral or extra-oral swelling that potentially compromise the patient’s airway
  • Trauma involving facial bones, potentially compromising the patient’s airway

Urgent dental care focuses on the management of conditions that require immediate attention
to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments. These should be treated as minimally invasively as possible.
  • Severe dental pain from pulpal inflammation
  • Pericoronitis or third-molar pain
  • Surgical post-operative osteitis, dry socket dressing changes
  • Abscess, or localized bacterial infection resulting in localized
    pain and swelling

  • Tooth fracture resulting in pain or causing soft tissue trauma
  • Dental trauma with avulsion/luxation
  • Dental treatment required prior to critical medical procedures
  • Final crown/bridge cementation if the temporary restoration is lost,
    broken or causing gingival irritation
  • Biopsy of abnormal tissue
Other Urgent Dental Care
  • Extensive dental caries or defective restorations causing pain
  •  Manage with interim restorative techniques when possible (silver diamine fluoride, glass ionomers)
  • Snipping or adjustment of an orthodontic wire or appliances piercing or ulcerating the oral mucosa
  • Suture removal
    Denture adjustment on radiation oncology patients
  • Denture adjustment or repairs when function impeded
  • Replacing temporary filling on endo access openings in patients experiencing pain


Routine or non-urgent dental procedures includes but are not limited to:
  • Initial or periodic oral examinations and recall visits, including routine radiographs
  • Routine dental cleaning and preventive therapies
  • Orthodontic procedures other than those to address acute issues (e.g. pain, infection, trauma)
  • Extraction of asymptomatic teeth
  • Restorative dentistry including treatment of asymptomatic carious lesions
  • Aesthetic dental procedures

Friday, March 20, 2020

Too Much Time on my Hands...

Too Much Time On my Hands

My buddy Dr. Paul Feuerstein always uses song titles for his articles.  I suppose imitation is the sincerest form of flattery… sorry Paul. Oh and also my apologies to the band Styx...

Last week, Covid-19 was a topic of discussion and an annoyance.  This week, it rocked the world. On Monday March 16th and Tuesday March 17th, my office was cranking along at a pace that made me proud.  Patient satisfaction was high, employees were happy, and the financial numbers were more than sound. Then there was “that huge sucking sound” that was Covid-19 tearing through the social fabric.  On Wednesday March 18th, everything changed for the office.

I was forced to furlough 6 employees, cut the hours of those who remained, and begin dismantling a schedule that was a snapshot of front office efficiency.

I’m pretty sure that all of you have similar stories to tell.  This has been an incredibly awful week and, even worse, there doesn’t appear to be any consensus on when this all will end.

My practice is now only treating emergencies and non-aerosol generating procedures.  Unfortunately those procedures are not nearly enough to cover overhead. I’ve done a little research in my limited downtime and from what I’ve discerned, cutting back to the level advised by multiple agencies and organizations will drop office production 85-90%.  You read that right. If your office has been producing $5000 per day, you can now expect about $750, and that would be on a good day. Covid-19 is not only going to affect biologic health, it is going to have a massive effect on financial health as well.

By limiting procedures in our offices we are helping to fight this disease on the front lines ( and as we know, we ARE on the front lines).  Our next step is to try and figure out ways to fight the other problems that this crisis is causing.  What follows here are some ideas on what to do with all of this time on our hands.

Clean, Clean, Clean
According to the Harvard Coronavirus Resource Center, a recent study found that the COVID-19 coronavirus can survive up to four hours on copper, up to 24 hours on cardboard, and up to two to three days on plastic and stainless steel. The researchers also found that this virus can hang out as droplets in the air for up to three hours before they fall. But most often they will fall more quickly.

Because we cannot be sure who in our office was positive for Covid-19 without showing symptoms, use this downtime to disinfect everything like you have never disinfected before.  I have instructed staff to clean and disinfect everything in our clinic.  When they are done doing this, I am going to instruct them to do the complete disinfection process again.  Perhaps that is overkill, but when it comes to the health of our patients, I think this thought process is the best one.

I am also going to have a similar strategy for our reception area.  Sometimes we forget about that spot when we are thinking about infection control.  Hopefully any virus left in that area would be dead in a few days, but in this case, better safe than sorry.

There have been some questions about surface disinfection.  Here is info from Kavo/Kerr regarding the surface disinfection product CaviWipes.  It is a short but enlightening read.

We are also going to devote time to completely cleaning and refreshing the office in general.  Not just for Covid-19 but to eliminate those embarrassing “dust bunnies” that can hide under furniture, cobwebs in corners, etc.  I will sometimes lay on the floor in the reception area and just look around to see if there are things that need to be cleaned. We’ve been so busy lately that I haven’t had a chance to do that, so now is the time!

If your office is like ours, these past few months have been very busy.  One of my associates, Dr. Sainy Adel, mentioned to me the other day that “since I’ve come on board, we’ve been pretty much pedal to the floor every day.”  He’s right. It has been a tremendously busy and productive time lately.

Like everything, that can be a blessing *and* a curse.  When things are busy, tasks such as organizing usually get less attention.  That means entropy sets in and things become more disordered. To that end, this is a great time to have dental assistants tear the operatories down to the bolts and get everything restocked and re-organized.  That will greatly help when this is over and the gates open. I am optimistic that when those gates open, there will be a flood of patients coming in and we will need to be prepared for that.

This also applies to the business office area.  We have 3 members on our Admin Team and sometimes even that many isn’t enough.  That means that their workspaces also get affected by entropy. They should also get ready for the tidal wave of things they’ll need to do when offices re-open.

Stay in Contact with Patients
Utilizing the technologies that we have at our disposal allows us to make sure that patients continue to think of us and put dentistry high on their priority list when all of this begins to fade.

Let patients know how much you miss being able to provide their care and what you are doing during this time to ensure their safety when you re-open.

Another good idea I heard lately was to have staff reach out to your elderly patients.  Let them know you care and ask if they need anything. Many of our elderly patients are frightened, immunocompromised, or both.  If you community allows you to be out in public, offering to make a grocery or pharmacy run could be a huge help to these people.  Plus it’s just the right thing to do. Dentistry has always had a tremendous social conscience and this is just one more way to help and to show our concern for  our older demographic.

Focus on Things You Can Control
We all have things in our offices that need more focus.  Maybe you’ve been wanting to improve your endo skills. Maybe you have been wanting to decide with CBCT system you’d like to purchase.

As Technology Evangelist, I’ve always got a long list of products to test and/or new things to focus on and implement.  I’m using this time to get my “To Do List” straightened up and things checked off. We’ll be working on making our newer implementations have tighter impact on our every day systems.  I’m going to be spending a lot of time with our Axsys 5x400 Mill and our SprintRay 3D printer.

I tell people all the time that dentistry is one of the few jobs where the CEO is also the one in charge of creating the majority of the product.  There are so many times when, as CEO, we think “if only I had some time to devote to ‘X’ business practice”. Guess what? Now you have that time.

Wrapping It Up
Work hard on being the leader you need to be.  Guide your team and your patients through this difficult time.  Before we know it, we’ll be back to full schedules and all the time eating problems we normally face.  Take this time to work on and fix those things you’ve been dreaming of fixing. Then get out there and work on making those dreams a reality!!!

Thursday, March 19, 2020

Facts about CaviWipes and SARS-COV-2 (novel coronavirus)


Protocols for Disinfection Efficacy on COVID-19

As of the date of this writing, there is currently no EPA recognized test protocol to evaluate disinfection efficacy against this specific novel coronavirus virus strain, SARS-COV-2 (Severe Acute Respiratory Syndrome Coronavirus 2), which causes COVID-19 (Coronavirus Disease 2019). Therefore, there is no EPA-registered surface disinfectant that bares a label claim against CDC recommends using products with EPA-approved emerging viral pathogens claims against COVID-19.
If an EPA-registered disinfectant with the Emerging Viral Pathogen claim is not available, products with the label claim against Human Coronavirus should be used according to the label instructions1.
CaviCide and CaviWipes Efficacy Regarding Coronavirus

CaviCide, which is the solution used to impregnate CaviWipes, has an EPA-registered label claim against Human Coronavirus. Metrex has recently performed an efficacy study on CaviWipes against the SARS-CoV (SARS-associated Human Coronavirus) in a third-party test lab. According to the study report, the study results passed the Viricidal Hard Surface Efficacy Test by exceeding a 3-log/ 99.9% reduction of the virus. However, this study result has not yet been reviewed or approved by the US EPA. CaviWipes does not have an Emerging Viral Pathogen claim, nor a labelling claim against Human Coronavirus.

Even though SARS-CoV, Human Coronavirus, and SARS-CoV-2 are not the same virus strains, all coronavirus strains are enveloped viral particles that belong to the same virus family of Coronaviridae. Enveloped viral particles are typically more susceptible to chemical disinfectant formulations than are other common pathogens2.

1. Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html. Accessed 3.3.2020.

2. Sattar, S. “Hierarchy of Susceptibility of Viruses to Environmental Surface Disinfectants: A Predictor of Activity Against new and Emerging Viral Pathogens”. Journal of AOAC International. 2007. Vol 90.6. https://www.researchgate.net/publication/5657319_Hierarchy_of_Susceptibility_of_Viruses_to_Environmental_Surface_Disinfectants_A_Predictor_of_Activity_Against_New_and_Emerging_Viral_Pathogens. Accessed 3.3.2020.

Wednesday, March 18, 2020

This Changes Everything...


It’s incredible how quickly the world changes.  Probably 2 weeks ago you wondered what that little ball in the picture above was.  Now you are probably tired of seeing it on every page you visit...

If you would have spoken with me on Sunday March 15th, I would have told you that the biggest problem we faced was the “toilet paper shortage of 2020”.

That just goes to show you how fast things can change.  In the short span of about 48-72 hours, life here in the U.S. was turned on its ear.  Suddenly we were told to avoid groups of 50, then 25, then 10.  States suddenly began to create programs of their own to deal with the spread of Covid-19.  The public and medical professionals needed guidance.  Unfortunately, the guidance was haphazard at best and non-existent at worst.

I spent a great deal of time on Sunday researching the science behind the pandemic and its spread.  I began reaching out to people who I consider much smarter than myself.  The problem I encountered was that there lots of “educated guesses” based on extensive training and years of professional experience, but there was one caveat… No one was sure… and *that* was the problem.

Throughout this crisis, those of us in the trenches, on the front lines of the attack, whatever analogy you want to use, we’ve been waiting for someone to make the decision.  No matter where I looked (and I looked at *a lot* of websites), the consensus was “use your best judgement as a practitioner”.  However, as a practitioner part of my decision making process is to know when I don’t have enough information and NEED more.  So I turned to the experts who, instead of providing leadership and recommendations, went with the “use your best judgement” approach.

This approach lead to a huge hole in our defenses as tens of thousands of us tried to figure it out by ourselves.  Emails were bouncing around the Internet like Super Balls at a county fair.  No one knew what to do and no one was offering direction on what to do.  The Hypcratic Oath states “above all, do no harm”, but we didn’t have any idea what would and what wouldn’t cause harm. 

On Monday morning, one state in the union advised offices to voluntarily cease treatment of elective procedures for 14 days.  I read the web page and found very little scientific information given for the recommendation.   Several hours later, in the late afternoon in the central U.S. I received an email from the American Dental Association asking all offices to do away with elective treatment for 21 days.  Even *less* scientific information and reasoning was given for their recommendation.  

One state advising 14 days caused some commotion.  The ADA advisory rolled a shockwave through the profession.  I feel there were 2 main reasons for the shockwave.  The first was the failure to disclose why this was advised.  Dentistry is a very data driven and scientific profession.  Doctors were wondering if they had missed some vital piece of information.  Was there something we missed?  Was there a previous announcement of data that we failed to see?

The second was the simple fact that most dental offices are small independent business entities.  Our employees *need* their jobs and doing away with elective treatment meant that not nearly as many staff would be needed.  Doctors *know* that their staff relies on them for steady income and suddenly hours would be drastically cut.  Layoffs would follow.  What would happen?  What about single parent staff members with children depending on them?  How do we deal with that?

The powers that be in the government had failed to even *remotely* prepare people for this.  It was also happening all across the country.  However as this situation unfolded, the CDC was still advising Universal Precautions and asking Covid-19 interview questions of patients pre-operatively.  I feel that IF leadership from the CDC had better informed us and better prepared us, perhaps the situation could have been handled much better.  Instead we were forced to sort of “make it up as we go along” which is rarely the proper way to deal with emergent situations.

Today March 18th, 2020 a White House press conference finally addressed the situation in a way I wished the federal government had from the beginning.  Seema Verma the Administrator for the Center of Medicare and Medicaid services said directly that elective procedures, including dental procedures, should be postponed.  At long last, we have someone standing up as a leader and telling us their best recommendation of how to deal with this, something that allows us to know what to do.  If that advice had come earlier there wouldn’t have been such a scramble and confusion.