Fox News Interview Covid 19
Dentist keeping you safe during Covid-19 Pandemic
A lot has happened since Governor DeSantis closed down our state and told us to cloister in our homes and do social distancing to prevent the spread of coronavirus. I told my staff and all that I met that I believe that this is the time that the Lord gave us to improve ourselves. Get closer to Him and to our families. If we were to be huddled together for safety, let this time be a time of positivity rather than one of despair and gloom. For me personally, I went on a quest to learn just as much as I could about coronavirus. This is a very transmissible disease through a virus and is not like the normal flu. The virus is spread through aerosols or tiny droplets of liquid when you are close to someone who coughs or sneezes or speaks or just breathes. But the big problem is that we now know that many people are asymptomatic and can be walking around and be unwitting carriers of this virus. Therefore, we must treat everyone like they may have the virus. We have done that in the past and still do treat anyone like they could be asymptomatic for AIDS, hepatitis, TB and a host of other bacterial and virus illnesses. In the dental office where aerosols have been generated already because of the drills and ultrasonic cleaning equipment, the risk of transmitting the COVID-19 virus is certainly much higher. What has the dental profession done to reduce the effects of aerosols in the dental environment.
Therefore, I have instituted massive and dramatic changes in our office for your safety and our safety. You will experience these changes when you come to our office. The American Dental Association has published guidelines for all dentists to follow as we come out of this lockdown together.
I want to assure you that the changes that I have instituted are far and beyond what the minimum guidelines that are recommended by the American Dental Association, the U.S. Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA)
YOU WILL SEE A HOST OF CHANGES THAT WILL OCCUR AT YOUR NEXT DENTAL APPOINTMENT IN THIS OFFICE. ALL OF THESE CHANGES ARE WAY FAR ABOVE AND BEYOND THE NORMAL DENTAL OFFICE FOR YOUR PROTECTION AND OUR MUTUAL PROTECTION. I WILL BE SENDING A LETTER TO YOU DESCRIBING ALL THE DIFFERENCES THAT ARE MEANT TO PROTECT YOU THE PATIENT AND WE THE STAFF OF OUR OFFICE. IF YOU HAVE ANY QUESTIONS ABOUT ANY OF THESE CHANGES, PLEASE FEEL FREE TO CALL OR EVEN TOUR OUR OFFICE AHEAD TO TIME. WE WILL BE GLAD TO SHOW YOU WHY WE BELIEVE THAT THIS OFFICE IS THE SAFEST DENTAL OFFICE IN ALL OF BREVARD COUNTY.
Richard Leong Jr DDS
REOPENING OF OFFICE AMID COVID-19 CRISIS
Governor DeSantis has decided that all medical dental offices can open again on May 4. But there is a new normal. Protocols for seeing patients in the dental office will be much different. The COVID- 19 virus has been shown to be passed through aerosols from a person who is contaminated with the coronavirus. These aerosols come from a person coughing or sneezing or even talking. These tiny droplets of liquid rest in the air for over three hours in a room. Or they can land on inanimate objects like the packaging in the grocery store or on the door handles are on the toilet handles or on light switches or hundreds of objects that the public touches in their daily routine. These droplets can remain active and live from between three minutes to several hours depending on the conditions of the environment and the place where the aerosols are distributed. Close contacts in certain businesses are more susceptible in the transmission of viruses. Viruses cannot live on their own. They must be transmitted to a human carrier mostly through the eyes, nose or mouth. That is why all medical instructions from any source will teach do not touch your face without first washing your hands. The virus then finds its way to the lungs where the respiratory effects are felt in the now infected patient. In the dental office where aerosols have been generated already because of the drills and ultrasonic cleaning equipment, the risk of transmitting the coven – 19 viruses are certainly much higher. What has the dental profession done to reduce the effects of the aerosols in the dental environment. Since many patients are asymptomatic, we must treat everyone like they have the virus. Just like we treated everyone that has AIDS or hepatitis or polio or TB in the same manner. They are asymptomatic and may not know that they have any illness.
1. PREVENTIVE MEASURES
You will be called ahead of time to tell you about the protocols of meeting you in the parking lot. Our recommendation is to not bring anyone with you except of necessity, like a caretaker or if you are a parent and need to accompany your child or your child needs to accompany you.
Any person with you who wants to come into the office will need to have the same pretreatment temperature taken and sign a consent form. The number of appointments will be limited so that there are no more than 2-3 patients in the office at one time. We will schedule the appointments so that there will be a minimum of traffic in the office at any one time. There may be a patient who is seeing Dr. Leong. There may be a patient who is seeing the hygienist. There may be a patient checking out.
2. MORE STRINGENT SOCIAL DISTANCING
The waiting room chairs are now spaced apart at least every 6 feet. You will be required to wash your hands when checking in. There will be hand washing soap in the waiting room and at the front desk. There will be trash cans to throw away the drying towels. You will need to sign statements and rather than sterilizing those pens for the next patient, you will be given the pen for your own use. Appointments are made where the patients do not have to wait. There should not be overlapping of patients as previously done where the dentist is moving room to room. Now the rooms must be prepared much differently for each patient. Those few people may choose to wait in the waiting room or in their car. But at any one time we should not have more than 2 people if possible, who are waiting for their family or friends
3. PREPARATION OF EACH OPERATORY
Draping of all areas with clear plastic where the aerosols could land which is all over the room especially 3-6 feet from the patient’s mouth. But research has shown that the tornado effect from the dental drill can spread aerosols around the entire operating room at least 30 feet from where the patient is being seated. Therefore, decontamination of each operatory must be done between each patient. Many procedures we did previously before COVID-19 but now even more time must be spending in between patient to sanitize the room to prevent spread of virus and bacteria from one patient to another. Plastic wrappings are put on countertops and handles of the light and on the operating table over the patient and on the dental chair. In between patients, alcohol and Lysol spray which has been the most effective in killing the virus will be used on the counters and surfaces around the room and in the air where the aerosol droplets remain. Each room must be totally decontaminated from the previous patients’ aerosols. Any handles that will be used to open or close cabinets must be covered ahead of time or be sterilized afterwards.
4. WORKING INSTRUMENTS THAT MUST BE STERILIZE IN HEAT/STEAM AUTOCLAVES
Previously all the drills and hand instruments were autoclaved. But certain other instruments could not be autoclaved because they were ruined because of the heat and steam. Now we have new instruments to take the place of the previous instruments that could not be sterilized. These new instruments must be sterilized or the virus is passed on between patient. Even wiping these instruments with alcohol and covering these instruments with plastic in between patients is inadequate. The 3-way syringe that is used to squirt water and air in the patient’s mouth must be sterilized. That previously could not be sterilized. The high-volume evacuator (HVE) suction is sterilized but the base of these suctions was never sterilized and they are touched every time to turn the suction on and off and must be sterilized. The motor of the drills where the drills are connected to the air and electricity to run the drills must be sterilized or not touched which can be contaminated with the virus.
Honestly most dental offices cannot afford to buy these new instruments that cannot be sterilized. They must rely on wiping them down with alcohol and covering them with plastic which many times is inadequate because they are not wiped down properly and are not covered with plastic.
Yet my feeling is what would I want in my mouth if I were sitting in that chair. I would want the best sterilization possible so I have the least chance of having coronavirus passed to me by an asymptomatic patient. Therefore, I have funded these very expensive new instrumentations because I know that no bacterial or virus will be passed on between patients when using sterilizable 3-way syringes and sterilizable HVE suction handle and saliva ejectors.
5. AIR FILTATION TO REMOVE AEROSOLS
Special equipment to remove the aerosols created by a dental visit must be either free standing in the operatory or mounted in the ceiling. Since aerosols linger in the air for over 3 hours if not mechanically removed, then in order to expedite patient flow, these air filtration devices must be utilized. I have spent thousands of dollars on equipping each operatory in my office with the best air purifiers that are made. These air purifiers transfer the entire air mass in the room five times an hour so that aerosols in the air that normally are there for 3 hours are gone during the same time that the patient is in the room. In my office we have the Blue air Pro L air purifier which has been rated the best on the market by Clinical Reports the premiere product dental products testing facility worldwide.
6. PERSONAL PROTECTIVE EQUIPMENT (PPE)
This abbreviation (PPE) is seen on the news and spoken of frequently. This designation means the outer garments and face equipment the dentist and his staff must wear to protect themselves from the virus contamination. This is the same PPE that is used in the hospital personnel use when treating COVID-19 virus. Again, we must treat everyone that comes into the office like they have the virus because many people are asymptomless and may have the virus and not know it. Disposable gowns covering the entire body with long sleeves are used. Gloves that cover the hands and are pulled up over the sleeves to prevent leakage of the virus onto the wrist and forearm is the proper fit. Face masks that are called ventilators and fit the face of the dentist and are higher filtration to stop viruses from penetrating to the dentist and vice versa to the patient from the dentist must be used. Eye protection in the form of glasses and/or goggles or face shields to keep aerosols out of the eyes of the dentist and staff. Eye glasses or goggles should be worn by the patient to keep viruses from getting into the eyes. Bonnets or surgical head shields should be worn by the dentist and staff to prevent aerosols on the hair must be worn.
Specific protocols must be maintained in the dental office just like in the hospitals. Donning of the PPE must be done is a certain way to prevent virus contamination. Once the appointment is done, specific methods of removing the PPE are mandated in order not to recontaminate the patient or the staff. Hands must be washed before doffing the PPE. Once the outer garment is doffed then hands must be washed again in order to remove the mask. Then the hands must be washed again in order to remove the head shield. Once the head shield is removed then the hands are washed again in order to don the next gown without contaminating from the last patient. Each patient coming into the office will be met by dental staff with new PPE so that no coronavirus in cross contaminated from one patient to the other.
7. CROSS CONTAMINATION FROM THE PATIENT TO THE DOCTOR AND VISE VERSA
The dentist and the patient could infect each other. Dental staff should be tested frequently to be sure that they have the antibioties and/or do not have the virus. Ideally patients should be tested ahead of time as to not contaminate the dental office and staff and other patients. But in today’s world testing for every person is not feasible or practical. First line defenders such as dental personnel should be tested. My staff and I were just tested for the coronavirus and antibioties in the 4th week of April so you know that we are not carriers.
8. HIGH VOLUME EVACUATION (HVE) DURING THE DENTAL VISIT
High volume suction has always been in the dental operatory. But now it must be used every time a procedure is done with a dental drill to reduce the number of aerosols significantly. Now there is more instrumentation to increase the amount of HVE in the mouth. Special equipment placed in the mouth and the HVE suction tube can be used. This special instrumentation call an Isolite uses high speed suction and covers and protects the throat and tongue at the same time. This instrument also has a light attached to it. This additional HVE suction is the first line of defense for aerosols. The little saliva ejector that is a tube that hangs out of the corner of the mouth to remove excess water has no effect on removing aerosols. So when you have your teeth cleaned or when you have fillings or crowns done, you will have 2 special HVE suctions going on at the same time to reduce the amount of aerosols produced by that appointment by 95%. This now is the first line of defense for removing aerosols in the patient’s mouth. The other aerosols are removed by the air purification units. Very few dental offices will have both HVEs in the mouth at the same time. Very few if any offices will have the air purification unit along with the two HVEs to essentially remove up to 100% of aerosols in the air. But if 95% of the aerosols are removed with HVEs then the rest removed by the air purification system that is the best method for keeping the patients and the staff safe.
9. USE OF RUBBER DAM DURING TREATMENT
This type of rubber mask that is clamped on to the adjacent teeth where the work is being done and used as a shield to cover the mouth is a very good way of preventing aerosols from entering the dental environment. There is a thin rubber mask that covers the throat and tongue and does not allow the saliva and contents of the mouth to be exposed while the drilling is going on. Therefore, there is less aerosols from the saliva containing virus. The aerosols above the dam are easier to control and suction. This type of mask is used most extensively when doing root canal treatments or fillings. This is an often-used protocol method even before coronavirus was a problem.
10. ELECTRIC EYE HAND WASH AND PAPER TOWEL DISPENSORS
To prevent cross contamination of virus and bacteria from one patient to another, automatic on/off water and automatic paper towel dispensers are a must so that the dental staff does not have to touch the facets or the towel dispensers. I have had electric eye technology in my office for a long time since we do so many surgical procedures. If you go to other offices and they don’t have electric eye water facet and electric eye paper towel dispensers then they must not touch the handles of the sink or the paper towel dispenser or they are contaminated again with the virus and bacteria. Then washing their hands did no good. Without electric eye technology it is almost impossible to not recontaminate your hands after washing them.
11. PROPER HANDWASHING FOR 20 SECONDS
This universal method of killing the virus and bacterial has been touted long before we had a COVID-19 scare but amazingly is not done even now. All people must take the time to wash their hands correctly for the proper amount of time of 20 seconds and on all surfaces of the hands and wrists and under the fingernails where the virus hides. Better to have no fingernails for dental staff or anyone. But that is a sacred cow for women. All rubber gloves have minute holes in them. No glove is perfect. Therefore, there is transfer of bacteria and virus from an operator’s hand to the patient and vice versa. That is why it is so important for the dentist to wash his hands before, during and after procedures to prevent cross contamination. That is why the dental assistant when donning and doffing their PPE must wash their hands correctly 4-5 times to keep viral transmission from the old PPE to the new PPE.
12. DISCIPLINE TO NOT TOUCH OTHER OBJECTS DURING TREATMENT
Any time the dentist or the staff touch anything else during the ongoing treatment there is contamination from the object they touched to the working field in the mouth. Inadvertent straightening of the glasses, touching of the handles of the desks or drawers where other equipment is stored, touching of computer keys, or x-ray handles that have not been sanitized or lead apron when taking x-rays, or pen or pencil sign a prescription. These actions can break the chain of prevention that was set up to prevent cross contamination from one person to the next person sitting in the chair. If something has to be done, the operator could pick up a tissue and adjust the eye glasses or open a drawer. Keyboards can be cover with a plastic wrap and changed in between patients. Handle that have to be utilized during the appointment can be covered with disposable blue wraps that can be changed in between patients.
13. USE OF BATHROOM FACILITIES AND WATER FOUNTAIN
If you need to use the bathroom while on the premises of our office, then you must notify the staff so that the bathroom can be sterilized after your use for the next person who may need to use the facilities.
The water fountain is closed for now because sterilization of the fountain is not possible to prevent cross contamination from one person to another.
14. INTERNAL BUILDING ARCHITECTURE
Dental offices with separate rooms with doors that close are better for preventing cross contamination in this environment of coronavirus. In our office we do have a closed environment where doors are closed not only for privacy but also to contain the coronavirus from escaping to the rest of the office.
When a dental office has operatories that are open with no doors, the aerosols are free to roam the entire office and contaminate the front desk area as well as all the other open operatories in the back part of the office.
Whereas the open concept was previously thought to be more modern and have the open-air concept that made the office look more spacious, today, this type of openness is a drawback when coronavirus is concerned.
15. STAFF INTERNAL COMMUNICATION
Making sure that we as a staff are efficient and preserve our guidelines for practice and prevent aerosols cross contamination in our flow patterns we need to communicate often during the day. Once we are in a room, we do not want to leave to prevent aerosols from leaving the room and so we don’t contaminate the space outside the rooms. There are times when we need to communicate for help or when we need any supplies or instruments. We now use communication devices that are handsfree voice actuated communicators so we don’t have to touch intercoms or phone lines. This system has made us better practitioners and made our days go more smoothly and safer. We also are cognizant of proper flow so that we preserve PPE and change at the correct times and not waste precious PPE.
16. DENTAL HYGIENE VISITS
The routine dental hygiene visits have changed. In order not to spread aerosols during this visit, we are refraining from using the routine ultrasonic high-speed cleanser as much as possible. The prophy jet polisher also spreads much aerosols in the air so we refrain from using these 2 pieces of equipment. Much more hand scaling will be done. We use the Isolite evacuation system for every appointment with the hygienist which is the high powered HVE system to suction 95% of the aerosols in the mouth before they reach the ambient air in the operatory.