Oral Hygiene Sep/Oct 2021 by dentalcommunity

oral hygiene , therapy , infection control , management and more ... VOL.31 NO.5

SEPTEMBER/OCTOBER 2021

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VOLUME 31 | NUMBER 5 SEPTEMBER/OCTOBER 2021

OH | CONTENTS

On the cover... The Piksters Hydropik Power Water Flosser removes 99.9% of plaque and is more effective than flossing for reducing gingival bleeding

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4 BRIEFS 6 NEWS & EVENTS 16 CPD CENTRE 20 ABSTRACTS

HCOVID-19: WHAT IS LIKELY TO HAPPEN IN THE NEXT PART OF THE PANDEMIC JOURNEY As various parts of Australia begin reopening, it’s important to consider what the next 12 months may hold in terms of the pandemic, explains Emer. Prof. Laurie Walsh

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Emer. Prof. Laurie Walsh outlines the science and practical considerations that support the proper treatment of dental suction lines, regardless of the nature of the dental service

Annual Subscriptions: Australia or NZ: OralHygiene $22.00 p.a. Overseas: A$38.00 p.a. Australasian Dental Practice (including OralHygiene) $99.00p.a. SUBSCRIBE ONLINE at http://shop.dentalpractice.com.au

WHY WHO MADE YOUR MASK MATTERS The TGA has expressed concerns regarding the quality and performance of masks for healthcare.

32 22

CLEANING SUCTION LINES A PRACTICAL APPROACH

facebook.com/auxiliarynow

twitter.com/auxiliarynow Publisher & Editor: Joseph Allbeury

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HAVE PROACTIVE CONVERSATIONS TO HELP PATIENTS FEEL SAFE With the ongoing threat of the COVID-19 pandemic, patients continue to be reluctant to visit dental clinics.

instagram.com/dentevents www.oralhygiene.com.au

Oral Hygiene (formerly Auxiliary) ISSN 1323-4919 is printed in Australia and published six times per year by Main Street Publishing P/L ABN 74 065 490 655 • PO Box 586, Cammeray 2062

Telephone: (02) 9929-1900 Facsimile: (02) 9929-1999 Email: info@dentist.com.au © 2021. All rights reserved. The contents of this magazine are copyright and must not be reproduced without the written permission of the publisher. Permission to reprint may be obtained upon application. Correspondence and manuscripts for publication are welcome. Although all care is taken, the editor and publisher will not accept responsibility for the opinions expressed by contributors to this magazine, or for loss or damage to material submitted for publication.

news | EVENTS

in | BRIEF

Pola Light whitening kit for patients now in 9.5% HP

Vaccines prevent COVID-19 transmission to close contacts

ust in time for changes to teeth whitening products able to be dispensed by dentists, the Pola Light patient kit with Pola Day 9.5% hydrogen peroxide gel now has premium packaging crafted to elevate the appeal of Pola Light above less effective pharmacy and on-line solutions on the market. This gives clinicians the confidence and support to convince customers of the benefits of professional tooth whitening.Pola Light is easy and comfortable to use at home, with treatment options from just 20 minutes a day. The gels are fast acting and are formulated to safely remove long term stains in as little as 5 days. The high viscosity, neutral pH tooth whitening gel ensures the greatest patient comfort in a take home kit. For more info, visit www.sdi.com.au.

New A-dec Third-Hand HVE Holder erosol capture in the dental surgery can be especially challenging in two-handed dentistry situations as well as in more complex four-handed dental procedures. Sometimes there are simply not enough hands to do the job, making you wish you had a “third hand” to hold onto something when you quite literally have your hands full. Well now you have! Thanks to a simple and practical solution from A-dec - the world’s leading dental equipment manufacturer, the A-dec ‘Third Hand’ HVE Holder makes it easier to practice two-handed dentistry while maintaining essential aerosol control. The flexible ‘Third Hand’ securely positions the HVE tip to within an inch (25mm) of the oral cavity - delivering precise, effortless aerosol capture while keeping your hands free. Contact A-dec on 1800-225-010 for more information.

An important question when making prognoses of the pandemic in the near future and of the need on nonpharmaceutical control measures is to what extent the vaccines reduce the likelihood of transmission from infected vaccinees. Several studies report high effectiveness of COVID-19 vaccines against SARS-CoV-2 infection and severe disease, however an important knowledge gap is the vaccine effectiveness against transmission (VET). This study presents estimates of the VET to household and other close contacts, based on data from the Netherlands covering the period from February to May 2021, using contact monitoring data. The Alpha variant of SARS-CoV-2 dominated during the study period. The final dataset contained 253,168 contacts of 113,582 index cases. During the study period, household members and other close contacts of confirmed cases needed to quarantine for 10 days post exposure. The secondary attack rate among household contacts was lower for fully vaccinated people (11%) compared to unvaccinated cases (31%), with an adjusted VET of 71% (95% confidence interval: 63-77). Stratified by vaccine received by the index case, VET values were 58% for AstraZeneca, 70% for Pfizer, and 88% for Moderna. The adjusted VET after only one vaccine dose was considerably lower than after two doses (15% for AstraZeneca, 26% for Pfizer and 51% for Moderna). Our study showed that the COVID-19 vaccines not only protect the recipient against SARS-CoV-2 infection, but also offer protection against transmission to close contacts after completing the full schedule. De Gier B, et al. Vaccine effectiveness against SARS-CoV-2 transmission and infections among household and other close contacts of confirmed cases, the Netherlands, February to May 2021. Euro Surveill. 2021;26(31):pii=2100640. DOI: 10.2807/1560-7917.

4 oral|hygiene

September/October 2021

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For clinical evidence confirming water flossing effectiveness, see these articles from peer reviewed dental journals– 1. *Oral irrigator removes 99.9% of plaque 2.

Pulse mode comfortably flexes gums to dislodge food particles.

Easy to use around dental bridges, braces and crowns, wires & splints.

Powerful jet removes bacteria deep below the gumline & between teeth.

Gorur A et al. Bioﬁlm removal with a dental water jet. Compend Contin Ed Dent 2009; 30 (Suppl 1):1 - 6.

**Oral irrigator is a more effective alternative to traditional dental floss for reducing gingival bleeding and improving oral health.

Rosema NAM et al. The eﬀect of diﬀerent interdental cleaning devices on gingival bleeding. J Int Acad Periodontol 2011; 13(1):2-10.

Oral irrigator and brushing up to 3X as effective for removing plaque around braces vs. string floss.

Cordless and waterproof - use it in the shower!

Sharma NC et al. The Eﬀect of a Dental Water Jet with Orthodontic Tip on Plaque and Bleeding in Adolescent Orthodontic Patients with Fixed Appliances. Am J Ortho Dentofacial Orthop 2008; 133(4):565-571.

Up to 2X as effective for improving gum health around implants vs. string floss.

Magnuson B et al. Comparison of the Eﬀect of Two Interdental Cleaning Devices Around Implants on the Reduction of Bleeding: a 30-day Randomized Clinical Trial. Compend of Contin Ed in Dent 2013; 34(Special Issue 8):2-7.

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in my | SURGERY

In my surgery...

By Tabitha Acret

ften at work, we have our head down and hands in someone’s mouth with little time to look at new or different products that can help make the day a little easier. In my role with the DHAA and as a KOL for a couple of dental companies, I get a lot of tips from colleagues and I also get to see a lot of new products early on. So for each edition of Oral Hygiene, I’ve been asked to share with my fellow clinicians some products, new and old, that I think we all should be using to make life easier for us, better for our patients and ideally, both!

n my surgery, I want my working life to be as easy and efficient as possible. I’m always looking for products that will save me time or allow me to operate more efficiently or remove the unnecessary difficulty from a task when I’m helping patients with their oral health care. The following three products are typical of what I look for to really make my life easier and in this case, by providing better care for patients, better vision for me and less hassle setting up for an education course. Dr Mark Hygienie

ooking after patients with dentures can be really confusing– depending on the website you look at, there can be a lot of contradictory information. Combine that with loss of patient dexterity or a caretaker not wanting to touch the denture and it’s not uncommon to find dirty dentures. A product I have found to be excellent with helping patients with poor manual dexterity that reduces damage caused by dropping and limits handling of the denture is Dr Mark’s Hygenie denture care device. By using this device, it can take less then a minute to clean the denture by using 360 bristles to clean all surfaces of the denture in conjunction with a denture cleaning solution. By locking it in the device, it avoids the denture being dropped in the sink and also allows care givers to clean the denture with minimal handling. The denture can then be stored in the airtight plastic box it comes in to stop growth of bacteria overnight. This has been a game changer for my patients who wear dentures in improving bacteria removal and I can really see a difference in their dentures when they return for their next appointment.

6 oral|hygiene

Single Use Instruments hilst travelling to different locations to teach hands on courses, I’ve been using single use instruments to teach with. It’s saved so much weight to lug around and has made the whole experience a lot easier with easy disposal afterwards in a sharps bin. Whilst many of you probably won’t need single use instruments for travelling teaching they are also great for mobile dentistry and aged care visits. The quality of a single use instrument is way better then I was expecting and depending on the state you’re in you can also access a recycling program.

Smart loupes oupes are one of the things I can’t live without in my surgery and I’ve been wearing loupes since Uni. I was recently looking into a second pair to use when teaching and came across an Australian dental hygienist who has a set of loupes business called Smart Loupes. They are a very affordable entry into the loupes market, coming in ranges from 2.5 to 3.5 magnification with the ability to buy a cordless light at the time of purchase or an add on later. I love supporting small business wherever I can and this is a great business support. Loupes are a must for all dental professionals but it shouldn’t have to break the bank! If you’re looking for an affordable entry into the market check out smart loupes

About the author Tabitha Acret graduated from Newcastle University with a Bachelor of Oral Health and is currently studying her Masters in Public Health. She was previously the National VicePresident for the DHAA. Tabitha currently works as a clinical educator for implant maintenance and non-surgical periodontal therapy and lectures nationally and internationally on motivating patients, implant maintenance, disease prevention and periodontal therapy. Outside of her busy work life of lecturing and working clinically in private practice, Tabitha enjoys volunteering both locally and internationally to raise awareness and education of the benefits of good oral health. She was the winner of the 2018 leadership award in dental hygiene and 2019 award for clinical excellence.

September/October 2021

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news | EVENTS

Single Dose solution for efficient and gentle cleaning and polishing of teeth

n the past year, Ivoclar Vivadent, one of the world’s leading suppliers of integrated solutions for high-quality dental applications and a comprehensive product and systems portfolio for dentists and dental technicians, presented the latest generation of its Proxyt prophy pastes. An optimised formula is responsible for the improved handling and longer storage period of the pastes as well as shorter cleaning and polishing times compared with the predecessor product. Now the company is introducing Proxyt Single Dose, which is a new delivery form that comprises two paste options for the quick, easy and hygienic treatment of all patients. Systematic and professional cleaning and polishing of teeth, restorations and implants is a standard treatment for preventing caries and periodontal and periimplant diseases. Smooth, clean and polished dental surfaces offer fewer possibilities for bacteria and plaque to accumulate. Apart from promoting oral health, professional oral care enhances pink and white aesthetics, making the teeth and gums look their best.

Designed for efficiency he new Proxyt Single Dose pastes from Ivoclar Vivadent have been developed with the aim of ensuring the efficient and effective cleaning and polishing of natural teeth, dental restorations and implants. They help keep teeth and restorations in impeccable condition and they maintain their natural-looking and aesthetic shine. The Single Dose cups can

8 oral|hygiene

be inserted into the corresponding prophy ring with ease. The unique formula and smooth consistency as well as the easyrinse properties allow plaque and tartar to be removed quickly and effectively and the surfaces to be polished to a high lustre. Furthermore, the Proxyt pastes from Ivoclar Vivadent adhere well to the teeth and instruments and therefore make handling easy. All these features combined considerably speed up the treatment process. Moreover, the pastes do not splatter or create a mess.

Gentle and effective cleaning and polishing ustomers can choose between two new Proxyt Single Dose paste options: fine and coarse. This helps to avoid unnecessary wear or abrasion of the tooth structure, restorations, implants or other prosthodontic appliances. Patients who have implants require special attention. Since they need professional teeth cleaning at regular intervals, the treatment they receive must be gentle and comfortable. Proxyt fine is a pumice-

free polishing paste that is exceptionally kind to sensitive fillings and tooth structure, such as dentine and dental enamel, as well as the surfaces of high-quality composite resin and ceramic restorations, for example, IPS e.max® from Ivoclar Vivadent. Proxyt fine is effective, gentle and minimally abrasive. It is suitable for restorations and implants. Furthermore, it is kind to sensitive gum tissue. The Proxyt pastes from Ivoclar Vivadent contain xylitol, which disturbs the metabolism of cariogenic bacteria. The mild mint flavour of the Proxyt pastes leaves a clean and fresh feeling in the mouth. It goes without saying that the needs of patients with intolerances are also taken into account. Proxyt pastes from Ivoclar Vivadent are 100% gluten and lactose free. A packet contains 200 cups (1.8 gm) including an adjustable prophy ring into which the cups can be effortlessly inserted. For more info, call 1300-IVOCLAR in Australia or in New Zealand, Freephone 0508-IVOCLAR.

September/October 2021

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news | EVENTS

Waterpik® Water Flosser: 3 times as effective as string floss for orthodontic patients

The effect of a dental water jet with orthodontic tip on plaque and bleeding in adolescent orthodontic patients with fixed appliances Sharma NC, Lyle DM, Qaqish JG, et al. Am J Ortho Dentofacial Orthop 2008; 133(4):565-571. Study conducted at BioSci Research Canada, Ltd., Mississauga, Ontario, Canada.

Objective o compare the use of a manual toothbrush and the Waterpik® Water Flosser with the Orthodontic Tip to manual toothbrushing and flossing with a floss threader on bleeding and plaque biofilm reductions in adolescents with fixed orthodontic appliances. A control group consisted of brushing only.

Methodology ne hundred and five adolescents with fixed orthodontics participated in this singlecentre, randomised study. Bleeding and plaque biofilm scores were collected at baseline, day 14 and day 28.

Results he Waterpik® Water Flosser was over three times more effective than flossing and over five times more effective than brushing alone for the reduction of plaque biofilm. For bleeding, the Water Flosser was 26% better than flossing and 53% better than brushing alone.

Conclusion dding a Waterpik® Water Flosser with the Orthodontic Tip to manual toothbrushing is significantly more effective at improving oral health in adolescent orthodontic patients than adding manual floss or brushing only.

10 oral|hygiene

September/October 2021

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infection | CONTROL

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COVID-19: What is likely to happen in the next part of the pandemic journey By Emeritus Professor Laurence J. Walsh AO

s various parts of Australia begin reopening, it’s important to consider what the next 12 months may hold in terms of the pandemic. Based on the history of previous pandemics and on current public health planning strategies for pandemic management, a number of predictions can be made around what the next year may bring.

12 oral|hygiene

Mutation he SARS-CoV-2 virus will continue to mutate1,2 and the designations will progressively move through the Greek alphabet. Due to replication errors that are typical for RNA viruses, spontaneous small mutations will occur frequently. Some of these may have no effect on the transmission and virulence of the virus and will largely pass unnoticed from a public health perspective. Other mutations will reduce the likelihood of transmission of the virus, particularly those that lower the affinity of binding of the virus to the ACE-2 receptor of human cells. Yet other mutations will make the virus more readily transmitted, or more stable in the environment. Typically, during the multiple waves of a viral pandemic, the virus becomes more readily transmitted but less virulent with successive waves of infection. This pattern was seen with the Spanish flu 100 years ago and with the swine flu in 2009.

September/October 2021

infection | CONTROL Spontaneous small mutations, also known as antigenic drift, occur with human influenza viruses, so the same is expected for this particular coronavirus.3 Antigenic shift, which represents a more substantial change in the genetic material of the virus, could occur in a patient who is infected at the same point in time with two or more strains of the virus. This could lead to a more concerning variant with greater potential to spread through the community. The likelihood that coronaviruses that are hosted by bats would escape their animal host and cause infections in humans was recognised over 20 years ago and there have been multiple near miss events where pandemics of coronavirus infection have been averted. Australian virologists have been studying that coronavirus escape pathways for over two decades, based on the prediction that a human pandemic was highly likely to occur.

Vaccine boosters he patterns of mutation in the virus will affect the requirements for boosters of the vaccine. They will also affect the design of future vaccines and boosters, since it will be necessary to choose parts of the virus (epitopes) that provide protection to new variants of concern.4-6 In this context, it is possible that vaccines that have multiple epitopes, such as inactivated or attenuated viruses, may prove to be useful, since these will present to the human immune system multiple epitopes of the envelope of the virus, as well as the spike protein. Tests to assess the level of immunity of an individual person will become increasingly important. Samples of blood or saliva may be used to track levels of protective antibodies. Knowing that a particular person’s levels of antibodies have waned below the level necessary to provide protection then provides the appropriate timing for a booster. Following such a personalised approach would maximise the value of using boosters, as it would identify those whose protective antibody response has a shorter duration than the median value in the population.

Vaccines for people of all ages

here are already moves to extend vaccination to children and this is

September/October 2021

appropriate given the fact that children can serve as reservoirs of infection for the virus and that in some children a rare inflammatory condition can lead to severe or fatal outcomes.7,8 Vaccination of children would also prevent the considerable public health impacts of “long COVID” over the lifetime of the child.

Mandatory vaccination oves around mandatory vaccination have progressed recently at supersonic speed, with multiple Australian jurisdictions moving to mandate vaccination for essential workers, including all those who work in healthcare in the public and private sectors.9-13 On October 1, AHPPC made clear its position supporting mandatory vaccination for all healthcare workers, which provides impetus to each jurisdiction to progress this through their own public health legislation and through the issue of public health directives.14

Sequestration of the disease nalysis of vaccine hesitancy indicates that it is not distributed evenly across the population and tends to be focused in certain subgroups. Overseas data indicate that in countries where the rates of vaccination are high, COVID-19 sequesters into these communities.15 Very often, such communities will have significant social disadvantage and may have more limited access to health care in general. As a consequence, the severity of outcomes following infection with COVID-19 is likely to rise. Public health planning at the level of local government areas needs to consider where hotspots of vaccine hesitancy exist at the present time, as the same areas will be a reservoir for ongoing infections into the future.

Targeted therapy range of new therapies for treating severe cases of COVID-19 have been developed, including humanised monoclonal antibodies16 and therapies that reduce the host inflammatory response in the lungs, or make human cells more resistant to infection by the virus. As these new therapies begin to be rolled out, the rates of “excess deaths” from COVID-19 and those who have access to such therapies should decline.

RAT testing: from the clinic to the household level n September, the TGA granted approval for the use of rapid antigen tests in dental practice to assess staff and also patients requiring emergency care. Protocols for using such tests have been published recently.17 The TGA has subsequently initially approved three COVID-19 self-tests (two saliva based and one that uses a nasal swab) for consumer use in Australia from 1 November 2021. Several Australian companies already manufacture rapid antigen tests for the international market, so following this approval, it is likely that such tests would be rapidly deployed into the general community. Australia has been one of the last OECD countries to permit the use of rapid antigen tests, which is an unusual point of history given that Australian manufacturing technology has been world leading in this particular field. With easy access to rapid antigen tests, individuals and the community will be able to assess their own status. The wide deployment of rapid antigen tests will also have implications for how these are used for those undertaking international travel. It is likely that rapid antigen tests based on saliva samples will become more widely used, because of the convenience of sample collection, as opposed to those using swabs of the nasopharynx.

Suppression versus elimination s individual local government areas and entire states and territories open up, public health authorities will be working from the standpoint of suppression, following what is known as “the hammer and the dance”. Empowered by the analysis of sewage for fragments of the virus and the wider use of rapid antigen tests, public health authorities will be able to better localise infection into specific geographical regions, to the level of a single suburb or below. As a result, any restrictions that need to be applied to the movement of people should be highly targeted and of relatively short duration. The need for massive lockdowns involving millions of people should decline sharply, as these more refined approaches become available.

oral|hygiene

infection | CONTROL

Figure 1. InnoScreen™ COVID-19 Rapid Antigen Test made in Australia and designed to be administered by suitably trained healthcare practitioners. When particular micro-regions are identified with unusually high levels of both asymptomatic and symptomatic infection, a vaccination blitz for that area will likely follow. This may use forms of the vaccine that only require a single injection, such as the Janssen vaccine.

Risk-based precautions n the “living with Covid” world, individuals with asymptomatic infections will continue to exist in the community and thus the use of sewage testing will continue to be important to identify where high numbers of such individuals may be located. Recognition of asymptomatic cases will improve with home-based rapid antigen testing, however it is naïve to assume that all possible cases in the community will be identified. Consequently, measures that can reduce the likelihood of transmission will continue to play an important role in the future. Considering a hierarchy of controls, elimination is the most desirable and effective strategy, hence ensuring that vaccination levels are high in the community remains an essential goal. Using effective preprocedural mouth rinse for patients at the start of their dental appointment is a further mechanism for reducing

14 oral|hygiene

Figure 2. From 1 November 2021, three COVID-19 self-tests (two saliva based and one that uses a nasal swab) have been approved for consumer use in Australia.

the likelihood that the patient saliva contains the virus. Extensive research efforts around preprocedural mouthrinses continues around the world, including clinical trials as well as laboratory assays of virus survival following exposure to different agents.18-24 Fortunately, all commonly used commercial mouthrinses are effective against SARS-CoV-2, meaning that any one dental practice has a wide range of agents to choose from.

High volume suction he COVID-19 pandemic has focused attention on the important protective role of high volume suction to remove aerosols generated by the normal breathing and speaking of patients (i.e. aerosol generating behaviours, or AGBs) as well as from dental procedures that use the triplex syringe or powered devices that generate aerosols (i.e. AGPs). Use of a large diameter (8 or 10 mm) suction tip provides the most effective removal of air from the patients oral cavity and the surrounding region.25-28 Further research into the value of extraoral suction and filtration devices will determine whether these have value either in the operatory or public areas of the practice such as the waiting room.

Air handling considerations he pandemic has brought attention onto the importance of air-conditioning systems and ventilation in reducing the level of viruses in the air and how this influences the waiting period or fallow time before an operatory can be used for the following patient. Recent research from the UK29 highlights that operatories which have no air-conditioning (i.e. no mechanical ventilation) have high levels of aerosols that persist for over one hour, however the levels drops once the windows are opened and natural ventilation is allowed to occur. On the other hand, a dental operatory that is connected to a central air-conditioning system which has air filtration capabilities shows a rapid decline in aerosol over 10 minutes, depending on the number of air changes per hour. Some dental operatories in Australia use a split system where the air inside the operatory is recirculated and this is likely to give a scenario similar to that of rooms with no mechanical ventilation. The topic of air handling in the dental practice (and the wider field of aerobiology) has some complexities and will be addressed in a future article.

September/October 2021

infection | CONTROL Conclusions

About the author

OVID-19 is likely to persist and sequester into parts of the community of Australia where it will remain for some years. The same pattern will be seen in parts of the world where access to health care is limited and the rollout of vaccination has been delayed. At the global level, COVID-19 will persist for several years and this will influence international travel. Parts of the world where COVID-19 vaccination has yet to be deployed at scale (such as in sub-Saharan Africa) are likely to sustain moderately high rates of infection in the community. On the other hand, the history of past pandemics has shown that there tends to be a strong economic rebound following a pandemic. In the case of the Spanish flu, this was the “Roaring 20s” which was an unheralded time of prosperity and social development in many parts of the world, which continued until the Great Depression. In all likelihood, there will be further viral pandemics in the future, which could arise from coronaviruses or from influenza viruses. Australia is now in a better position than it was in 2019 to cope with such future pandemics. We now have onshore production of surgical masks and respirators, in both Adelaide and Brisbane, and a proper facility for testing the performance of such devices, which did not exist before the COVID-19 pandemic. The ability of Australian researchers to develop vaccines and diagnostic tests has been enhanced greatly through the pandemic and this will be an advantage for future pandemics. Last of all, but not least, most of the community has come to a better understanding of hygiene measures that will reduce the spread of respiratory viruses. This is why there has been a spectacular decline in the number of cases of viral influenza in Australia during the COVID-19 pandemic. It is often remarked that those who do not learn the lessons of the past are destined to repeat them. Fortunately, it seems that, from a public health perspective, some lessons have been learnt and some lessons from the past that have been forgotten have been revisited and refreshed for the modern age.

Emeritus Professor Laurence J. Walsh AO is a specialist in special needs dentistry who is based in Brisbane, where he served for 36 years on the academic staff of the University of Queensland School of Dentistry, including 21 years as Professor of Dental Science and 10 years as the Head of School. Since retiring in December 2020, Laurie has remained active in hands-on bench research work, as well as in supervising over 15 research students at UQ who work in advanced technologies and biomaterials and in clinical microbiology. Laurie has served as Chief Examiner in Microbiology for the RACDS for 21 years and as the Editor of the ADA Infection Control Guidelines for 12 years. His published research work includes over 330 journal papers, with a citation count of over 15,400 citations in the literature. Laurie holds patents in 7 families of dental technologies. He is currently ranked in the top 0.25% of world scientists. Laurie was made an Officer of the Order of Australia in January 2018 and a life member of ADAQ in 2020 in recognition of his contributions to dentistry.

September/October 2021

References 1. Tian D et al. The global epidemic of SARS-CoV-2 variants and their mutational immune escape. J Med Virol. 2021 Oct 5. doi: 10.1002/jmv.27376. 2. Ciotti M et al. The COVID-19 pandemic: viral variants and vaccine efficacy. Crit Rev Clin Lab Sci. 2021 Oct 1:1-10. doi: 10.1080/10408363.2021.1979462. 3. Volkan E. COVID-19: structural considerations for virus pathogenesis, therapeutic strategies and vaccine design in the novel SARS-CoV-2 variants era. Mol Biotechnol. 2021 Oct;63(10):885-897. doi: 10.1007/ s12033-021-00353-4. 4. Mahmoodpoor A et al. SARS-CoV-2: unique challenges of the virus and vaccines. Immunol Invest. 2021 Oct; 50(7):802-809. doi: 10.1080/08820139.2021.1936009. 5. Tao K et al. The biological and clinical significance of emerging SARS-CoV-2 variants. Nat Rev Genet. 2021 Sep 17:1-17. doi: 10.1038/s41576-021-00408-x. 6. Bano I et al. Genetic drift in the genome of SARS COV-2 and its global health concern. J Med Virol. 2021 Sep 15. doi: 10.1002/jmv.27337. 7. Schulert GS et al. Host genetics of pediatric SARSCoV-2 COVID-19 and multisystem inflammatory syndrome in children. Curr Opin Pediatr. 2021 Sep 15. doi: 10.1097/MOP.0000000000001061. 8. Chauhan N et al. Optimizing testing regimes for the detection of COVID-19 in children and older adults. Expert Rev Mol Diagn. 2021 Oct;21(10):9991016. doi: 10.1080/14737159.2021.1962708. 9. Tasmania https://www.coronavirus.tas.gov.au/ important-community-updates/mandatory-vaccination-of-health-care-workers

10. Victoria https://mvec.mcri.edu.au/references/ covid-19-mandatory-vaccination-directions-in-victoria 11. WA https://ww2.health.wa.gov.au/About-us/ Policy-frameworks/Public-Health/Mandatoryrequirements/Communicable-Disease-Control/ Immunisation/COVID-19--Mandatory-Vaccinationand-Vaccination-Program-Policy 12. QLD https://www.childrens.health.qld.gov.au/ wp-content/uploads/PDF/COVID-19/mandatoryCOVID19-vaccination-faqs.pdf 13. NSW https://www.nsw.gov.au/covid-19/vaccination/requirements-for-workers 14. https://www.health.gov.au/news/ australian-health-protection-principal-committeeahppc-statement-on-mandatory-vaccination-of-allworkers-in-health-care-settings 15. Chau NVV et al. Oxford University Clinical Research Unit COVID-19 Research Group. The natural history and transmission potential of asymptomatic SARS-CoV-2 infection. Clin Infect Dis. 2020; 71(10):2679-2687. 16. Mornese Pinna S et al. Monoclonal antibodies for the treatment of COVID-19 patients: An umbrella to overcome the storm? Int Immunopharmacol. 2021 Sep 28;101(Pt A):108200. doi: 10.1016/j. intimp.2021.108200. 17. Durner J et al. SARS-CoV-2 and regular patient treatment – from the use of rapid antigen testing up to treatment specific precaution measures. Head Face Med. 2021;17:39. DOI: 10.1186/s13005-021-00289-9. 18. Davies K et al. Effective in vitro inactivation of SARS-CoV-2 by commercially available mouthwashes. J Gen Virol. 2021;102(4):001578. 19. Xu C et al. Differential effects of antiseptic mouth rinses on SARS-CoV-2 infectivity in vitro. Pathogens. 2021;10(3):272. 20. Stathis C et al. Review of the use of nasal and oral antiseptics during a global pandemic. Future Microbiol. 2021;16(2):119-130. 21. Mateos-Moreno MV et al. Oral antiseptics against coronavirus: in-vitro and clinical evidence. J Hosp Infect. 2021;113:30-43. 22. Komine A et al. Virucidal activity of oral care products against SARS-CoV-2 in vitro. J Oral Maxillofac Surg Med Pathol. 2021;33(4):475-477. 23. Eduardo FP et al. Salivary SARS-CoV-2 load reduction with mouthwash use: A randomized pilot clinical trial. Heliyon. 2021;7(6):e07346. 24. Seneviratne CJ et al. Efficacy of commercial mouthrinses on SARS-CoV-2 viral load in saliva: randomized control trial in Singapore. Infection. 2021;49(2):305-311. 25. Meethill AP et al. Sources of SARS-CoV-2 and other microorganisms in dental aerosols. J Dent Res. 2021; 1-7. DOI: 10.1177/00220345211015948. 26. Allison JR et al. Evaluating aerosol and splatter following dental procedures: addressing new challenges for oral health care and rehabilitation. J Oral Rehabil. 2021; 48:61-72. 27. Holliday R et al. Evaluating contaminated dental aerosol and splatter in an open plan clinic environment: Implications for the COVID-19 pandemic. J Dent. 2021; 105: 103565. 28. Balanta-Melo J et al. Rubber dam isolation and high-volume suction reduce ultrafine dental aerosol particles: an experiment in a simulated patient. Appl Sci. 2020; 10: 6345. 29. Shahdad S et al. Fallow time determination in dentistry using aerosol measurement in mechanically and non-mechanically ventilated environments. Brit Dent J. 19 July 2021 DOI: 10.1038/s41415-021-3369-1.

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COVID-19: What is likely to happen in the next part of the pandemic journey

Cleaning suction lines a practical approach

By Emeritus Professor Laurence J. Walsh AO

By Emeritus Professor Laurence J. Walsh AO Mutation

dental suction system is designed to remove saliva, blood, remnants of dental hard tissue and dental materials and debris generated during clinical procedures from the mouth. By removing these, dental suction makes clinical procedures faster as well as safer. This is true whether one is working in a regular clinic with a dental chair or from a mobile dental delivery system. This article outlines the science and practical considerations that support the proper treatment of dental suction lines, regardless of the nature of the dental service.

he SARS-CoV-2 virus will continue to mutate and the designations will progressively move through the Greek alphabet. Due to replication errors that are typical for RNA viruses, spontaneous small mutations will occur frequently. Some of these may have no effect on the transmission and virulence of the virus and will largely pass unnoticed from a public health perspective. Other mutations will reduce the likelihood of transmission of the virus, particularly those that lower the affinity of binding of the virus to the ACE-2 receptor of human cells. Yet other mutations will make the virus more readily transmitted, or more stable in the environment. Typically, during the multiple waves of a viral pandemic, the virus becomes more readily transmitted but less virulent with successive waves of infection. This pattern was seen with the Spanish flu 100 years ago and with the swine flu in 2009.

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1,2

Effective suction for reducing aerosols ffective high volume evacuation is recognised as a key component of strategies that mitigate the risk of infection to dental staff, including from aerosolgenerating procedures performed on dental patients with upper respiratory tract infections. Highvolume evacuation (HVE) using wide bore intraoral suction tips has been shown to be highly effective in reducing salivary contamination of the surrounding environment.

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Question 1. During multiple waves of a viral pandemic, a virus typically becomes:

Question 6. Liquid from the saliva ejector’s low volume evacuation suction line can enter a patient’s mouth during use when:

a. More readily transmitted and more virulent. b. More readily transmitted but less virulent. c. Less readily transmitted but more virulent. d. Less readily transmitted and less virulent.

a. Occlusion of the mouthpiece opening by the oral mucosa. b. There are oscillations in suction produced by operating other suction equipment. c. A patient sucks or close their lips around the saliva ejector. d. All of the above.

Question 2. A range of new therapies for treating severe cases of COVID-19 include: a. Humanised monoclonal antibodies. b. Therapies that reduce the host inflammatory response in the lungs. c. Therapies that make human cells more resistant to infection. d. All of the above. Question 3. A dental operatory that is connected to a central air-conditioning system with air filtration capabilities shows a rapid decline in aerosols in around: a. 10 minutes b. 30 minutes c. An hour d. Two hours Question 4. A RAT is a: a. Rapid Allogen Treatment. b. Responsive Antigen Treatment. c. Rapid Antigen Test. d. Rapid Allogen Treatment. Question 5. All commonly used commercial mouthrinses are effective against SARS-CoV-2: a. True b. False

Question 7. Flushing with an appropriate antimicrobial solution can fail because: a. Frequency of flushing is too low. b. Volume of product used is too low. c. Solution is too diluted. d. Tap water used for product dilution is hard. e. All of the above. Question 8. High volume suction is defined as: a. 40 L/min air b. 90 L/min air c. 159 L/min air d. 250 L/min air e. 350 L/min air Question 9. Correct placement of HVE can reduce aerosols and spatter by over: a. 95% b. 90% c. 85% d. 80% Question 10. To dissolve mineral scale, suction system cleaners use: a. Weak acids. b. Strong acids. c. Mineral chelators. d. Calcium carbonate.

INSTRUCTIONS: OralHygiene™ is now offering PAID subscribers the ability to gain 2 Hours CPD credit from reading articles in this edition of the magazine and answering the questions above. To participate, contact OralHygiene for your Username and Password. Then log into the Dental Community website at www.dentalcommunity.com.au and click on the CPD Questionnaires link; select the Oral Hygiene Sep/Oct 2021 questionnaire and then click START. A score greater than 80% is required to PASS and receive CPD.

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Have proactive conversations to help patients feel safe

Why who made your mask matters

When COVID-19 created an unprecedented demand for personal protective equipment (PPE), many countries were caught off guard. Without sufficient stockpiles of items such as masks, gowns and gloves, shortages developed in these disposable items. As demand began to surpass available supply from reputable manufacturers, clinicians tried to source these from wherever they could. Around the world, some companies were eager to profit from the increased demand for consumer level masks, as well as masks for health care. It is fair to say that some of these manufacturers had no medical device manufacturing experience and no knowledge of the regulatory requirements that are in

place in Australia to keep healthcare professionals safe. There has been confusion over domestic use personal masks (that have no splash protection) and masks for healthcare. The TGA has expressed concerns regarding the quality and performance of masks for healthcare. Masks for use in healthcare need to have protection from fluid penetration, be approved by the TGA for medical use and meet the filtration and splash protection requirements of AS 4381:2015. Many imported masks and products sold online do not meet these requirements. Using inferior masks puts users at risk of infection in the workplace. In the midst of the COVID-19 pandemic and dealing with a virus that is as highly transmissible as SARS-CoV-2 (and the Delta variant in particular), choosing a mask that meets these standards is more important than ever. In some cases, poor quality masks could even contain potentially harmful materials* that pose a risk to health. Producing face masks suitable for use in a healthcare setting requires considerable knowledge and experience in the fabrication

28 oral|hygiene

Patient communication is key to alleviating the fears that keep patients from returning to your dental practice.

Why is patient communication important? s the pandemic continues, many patients continue to practice caution and may be eager to avoid places where they can’t remain masked, such as at a dental practice. We don’t have to point out that patients have a tendency to delay cleanings and

a. True b. False Question 12. Masks used in dentistry should be certified to comply with Australian Standard: a. AS 4187:2014 b. AS 4381:2015 c. AS 4381:2002 d. AS 4031-1992 Question 13. A Level 2 mask provides protection again fluid pressure of up to: a. 80 mm Hg b. 120 mm Hg c. 140 mm Hg d. 160 mm Hg e. 180 mm Hg Question 14. Level 2 masks must have a Bacterial filtration efficiency rate greater than:

regular check-ups to begin with, so the pandemic-related concerns only exacerbate the problem. The best way to alleviate these concerns is to be proactive with communication, so patients know - even before asking - that you’re taking every precaution to keep them safe and prevent infection. So, be sure to develop a communications plan that will ensure patients receive consistent, clear and accurate information about your infection control practices. Your outreach can include channels like social media posts, an email bulletin to patients, signage in your practice itself and perhaps most importantly, staff-patient communications.

Be prepared to have candid conversations hen you think about who spends the most time with patients, it’s often front office staff and dental assistants. But the truth is, patients who have questions may approach anyone in the practice. That’s why everyone needs to be fully trained and prepared to talk with patients about the safety measures the

practice is taking and any concerns they have, regardless of their role. You should be well-versed in the latest protocols so you can answer patients’ most common questions about safety, sterilization, and anything else your patients present. One way to keep abreast of the latest guidelines pertaining to COVID and infection prevention is to make use of the ADA COVID-19 microsite, which helps all members of the dental team members stay up-to-date on the latest topics.

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September/October 2021

Question 11. Masks for use in dentistry must be included in the ARTG before being imported into or supplied in Australia, exported from Australia, or advertised in Australia:

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Question 16. The best way to communicate with patients that you are taking every precaution to keep them safe is using: a. Social media posts. b. An email bulletin. c. Signage in your practice. d. Staff-patient communications. e. All of the above. Question 17. A common question asked by patients is: a. What does your practice do with instruments after they’ve been used on patients? b. Why do you clean and sterilise instruments between each patient? c. How does your practice sterilise the instruments? d. How do patients know instruments are sterile when they are used? e. All of the above. Question 18. Everyone at the practice should know: a. At what stage masks are required. b. The social distancing requirements in the waiting room. c. Can patients bring someone with them or do they need to be alone. d. Under what situations can caregivers be in the treatment room. e. All of the above.

a. 90% b. 95% c. 97% d. 98% e. 99%

Question 19. When it comes to helping patients become more comfortable with your safety measures and infection control practices, there is such a thing as too much information:

Question 15. Level 3 masks must have a Delta P less than:

Question 20. It’s important to pre-emptively let patients know:

a. 5.0 b. 4.0 c. 3.0 d. 2.0 e. 1.0

a. What steps does your practice takes for infection control. b. How can they know that the clinic is doing everything it can for infection control. c. What should to they if they become ill just before their appointment. d. All of the above.

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Learn firsthand from Australia’s leading authority on infection prevention and control in dentistry about recent changes in infection control that have come in over the past 12 months, including the new guidelines from NHMRC (May 2019), Hand Hygiene Australia HOURS CPD (Sept 2019) and the CDNA (Dec 2018) as well as recent changes in Australian Standards and TGA regulations that are relevant to infection control. The course will provide a summary of how those changes interlink with one another. The course will cover practical implementation of the new requirements and what it means for everyday dental practice. Hear about the why and the how and keep up-to-date with the changes that are happening. Bring along your questions in writing or in person for one of the Q&A sessions that will be held during the day.

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FULL UPDATE! All the changes to Infection Control Guidelines in 2020

Professor Laurence Walsh AO is a clinically active specialist in special needs dentistry who is based at the University of Queensland in Brisbane. Laurie has been teaching infection control and clinical microbiology for over 25 years at postgraduate level and has been the chief examiner in microbiology for the RACDS for the past 20 years. He has presented invited courses and lectures on infection control across Australia and internationally. Laurie has written over 60 articles on infection control and in addition published over 320 journal papers and a further 190 technical reports and literature reviews. He serves on two committees of Standards Australia (personal protecting equipment; and instrument reprocessing) and in recent years has been an adviser to the Communicable Diseases Network of Australia and the Australian Commission on Safety and Quality in Health Care. Laurie has been a member of the ADA Infection Control Committee since 1998. He has contributed to various protocols, guidelines and checklists and manuals used in Australia.

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Infection Infection Contol Contol Boot Boot Camp Camp is is presented presented by by Dentevents, Dentevents, aa division division of of Main Main Street Street Publishing Publishing Pty Pty Ltd Ltd ABN ABN 74 74 065 065 490 490 655 655 •• www.dentevents.com www.dentevents.com •• info@dentist.com.au info@dentist.com.au ™ ™ and Dentevents™ ™ are trademarks of Main Street Publishing P/L © 2020 Main Street Publishing Pty Ltd Tel: (02) 9929 1900 • Fax: (02) 9929 1999 • Infection Contol Boot Camp Tel: (02) 9929 1900 • Fax: (02) 9929 1999 • Infection Contol Boot Camp and Dentevents are trademarks of Main Street Publishing P/L © 2020 Main Street Publishing Pty Ltd

abstracts | 2021

Oral Hygiene Abstracts 2021

By Emer. Prof. Laurence Walsh AO

Engineering controls for safe dental practice

Aerosol generating procedures in dental health care can increase the risk of transmission of the virus. Due to the risk of infection of both dental healthcare workers and patients, additional infection control measures for all patients are strongly recommended when providing dental health care. While aerosols may not play a major role in transmission of COVID-19 in most daily activities, the situation is different in the dental clinic. Water, in combination with compressed air used for coolant and spraying, causes aerosols which become contaminated with micro-organisms from the oral cavity. Dental staff operate at a distance of 60 cm or less from a patient’s oral cavity and the greatest microbiological contamination within dental clinics is within 1 m from the oral cavity, via both splashes and aerosols. Thirty minutes after aerosol formation, virus particles and bacteria can still be detected in the air of the treatment room. Thus, the air in the treatment room after an aerosol generating procedure should be regarded as contaminated. Dispersion of the virus throughout the dental clinic should be avoided, thus working under negative air pressure would be preferable, as clean air will be drawn from less contaminated areas towards the treatment room. At the same time, an active exhaust flow from the contaminated treatment room leads to removal of possible pathogens from the air. In most dental clinics, working under negative air pressure is not possible. Sufficient ventilation in the room can dilute airborne viruses and natural ventilation can also be used, as well as waiting at least 30 minutes between patients. Volgenant CMC et al. Infection control in dental health care during and after the SARS-CoV-2 outbreak. Oral Diseases. 2020;00: 1–10. DOI: 10.1111/odi.13408.

Air handling, ventilation and dental aerosol generating procedures in dental practice

Aerosols, particularly when highly concentrated in enclosed environments, play an important role in the transmission of COVID-19. Aerosols in dental procedures are particles smaller than 5 μm that can remain suspended in air for hours. As a result of risks associated with COVID-19, within the UK the use of a resting period, known as the fallow time (FT), has been recommended to allow for settling of suspended aerosol following dental aerosol generating procedures (AGPs). <em>In vitro</em> simulation of fast handpiece cavity preparations using a manikin was conducted using an Optical Particle Sizer and a NanoScan device at baseline, during the procedure and after the fallow period. AGPs were simulated on a dental manikin in the Royal London Dental Hospital (London, UK) with mechanical ventilation with six air changes per hour through a centralised air exchange system. The same procedures were repeated in a private dental clinic in Harley Street, London, without natural ventilation. AGPs were carried out using an air turbine for 20 minutes while simulating cavity preparation of tooth 36 and crown preparation of 31 and 21, with air and water coolant at maximum flow. All procedures were carried out using a four-handed dentistry technique which included the assistant operating high-volume suction and a saliva ejector. When AGPs were carried out in a room with no mechanical ventilation or air conditioning, baseline particle levels were not achieved even after resting the room for one hour. In contrast, when windows were opened after AGPs, there was an immediate reduction in particles. In airconditioned hospital environments, the particle count returned to baseline within ten minutes following the AGP. Careful four-handed dentistry with high volume suction is an important mitigating method. Effective central airconditioning with high-efficiency particulate air filtration, along with high-volume dental suction, resulted in reduction of fallow time to just 10 minutes. Non-ventilated rooms failed to reach baseline level even after one hour of fallow time. Hence AGPs are not recommended in dental surgeries where no ventilation is present or possible. Shahdad S et al. Fallow time determination in dentistry using aerosol measurement in mechanically and non-mechanically ventilated environments. Brit Dent J. 19 July 2021 DOI: 10.1038/s41415-021-3369-1.

Practical points for using rapid antigen tests in a dental clinic

Rapid antigen tests (RATs) are a practical tool for identifying potentially infected individuals. One can not only isolate and identify infected patients, but also select the appropriate infection prevention and control measures for the patient. According to the WHO, RATs have a minimum performance requirement set at ≥ 80% sensitivity and ≥ 97% specificity, which is lower than those for the reverse transcription-quantitative polymerase chain reaction (RT-qPCR) tests. RATs perform best in cases with high viral load, in presymptomatic and early symptomatic cases. Even when RATs are available for use, it is recommended that all patients are triaged before any appointment (preferably by phone and prior to entering the dental office) to determine their COVID-19 status. In suspicious cases, RATs can be applied to identify a potential infection in a patient or a staff member. Positive results can then be sent for testing using RT-qPCR. In patients with a positive RAT result, only emergency treatments should be performed and using full riskbased precautions. To minimise risk, it is recommended to test dentists and their staff on a regular and frequent basis (e.g. twice or more each week) depending on the actual infection level in the community and the advice of local authorities. To incorporate RAT in the dental practice, aspects like additional time requirements, the incorporation of the test results in the practice workflow, staff training and the test costs need to be addressed. Durner J et al. SARS-CoV-2 and regular patient treatment - from the use of rapid antigen testing up to treatment specific precaution measures. Head Face Med. 2021;17:39. DOI: 10.1186/s13005-021-00289-9.

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September/October 2021

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Cleaning suction lines a practical approach By Emeritus Professor Laurence J. Walsh AO

22 oral|hygiene

September/October 2021

infection | CONTROL There is an extensive literature that supports the view that with correct placement of HVE, aerosols and spatter should be reduced by 90% or more.1-14 This makes maintaining the suction system a critical component of safe working practices in everyday dental practice. HVE also reduces contamination in the areas immediately beyond the dental chair when open plan clinic designs are used, keeping the majority of contamination within 1.5 m of the patient’s head. The reason for this is that suction removes smaller lighter droplets (aerosol) easily and it is these that likely cause more distant contamination. These considerations explain why dental suction with a wide bore aspiration tip fitted to HVE should be an essential component of dental treatment, especially for dental chairs in an open plan clinic layout.15

Suction line configurations urrent definitions for dental suction are as follows: low volume (40 L/ min air), medium volume (159 L/min air) and high volume (250 L/min air).16 High volume suction hoses usually are equipped with special connectors and adapters into which wide bore (8 or 10 mm diameter) suction tips are fitted prior to each patient treatment. The tip will move ~4 litres of air per second, or more. HVE connectors often contain valves to regulate suction strength. They may also have metal or plastic adaptors to join various tips to the suction hose. In contrast, single patient-use saliva ejector tips (3-4 mm in diameter) are fitted to the low volume suction line. This line moves only ~1 litre of air per second or less. HVE is essential during all aerosolgenerating procedures, including those using handpieces, ultrasonic and sonic devices, air polishing devices and hard tissue lasers.8,13,17 Different designs of suction tips and attachments can enhance the protective action of suction by better removal of aerosols during caries removal with a high-speed handpiece and other dental aerosol-generating procedures. As well, correct placement of the tip of the high-volume evacuator, facing the aerosol-generating procedure side, will significantly reduce the level of ultrafine particles produced during restorative dentistry.18,19

September/October 2021

The Isolite® illuminated isolation system attaches to the HVE connector and is designed for use by clinicians such as dental hygienists who are working without a dental assistant. The Isolite is designed to provide simultaneous suction to both the maxillary and mandibular quadrants on one side, as well as illumination. Its performance for achieving aerosol reduction has been challenged, with a clinical study of its use during ultrasonic scaling showing no benefit over a saliva ejector. Neither the Isolite device nor the saliva ejector can effectively reduce aerosols and spatter during ultrasonic scaling.20

Saliva ejectors and low volume evacuation everal studies from the 1990s have shown that, under certain conditions, liquid from the saliva ejector’s low volume evacuation suction line can enter a patient’s mouth during use. This can occur in a transient way accidentally when there is occlusion of the mouthpiece opening by the oral mucosa, or when there are oscillations in suction produced by operating other suction equipment. It can also occur deliberately when patients apply greater suction force than what is provided by the saliva ejector, as they suck or close their lips around the saliva ejector. In this case, the negative pressure in the patient’s mouth is greater than that in the saliva ejector, causing backflow of previously aspirated fluids. Gravity assists such backflow when the LVE suction tubing holding the tip is positioned above the patient’s mouth.21,22 Microbiological studies of saliva ejector low velocity suction lines reveal that these are coated with microbial biofilms. The dense deposits of metabolically active Gram-positive cocci and Gram-negative bacilli are embedded in an extensive polysaccharide matrix.23 Saliva ejector lines are just as contaminated as HVE suction lines and a wide variety of microorganisms are present. Hence, retraction of oral fluids and biofilm-derived microorganisms from contaminated suction hoses could potentially be a source of cross-contamination and cross-infection. When oral fluids from a previous patient are taken into the mouth, there is also the risk of transmission of viruses that may be present in

saliva, including Epstein Barr virus, cytomegalovirus, Herpes Simplex and other herpes group viruses.24

Removing hard deposits from suction lines veryday maintenance of suction lines is essential. These lines are prone to the accumulation of mineral deposits as well as microbial biofilms. Formation of mineral deposits can be promoted by materials suctioned from the oral cavity, like remnants of fluoride gels, prophy paste, abrasive powders and cements, because these contain anions (such as carbonates, phosphates, sulphates and hydroxides) that can form insoluble precipitates with metal cations (such as calcium, magnesium and aluminium). Mineral formation will be faster when the water exiting from the dental unit is hard, as hard water has higher levels of such anions and cations and a higher propensity to form mineral scale deposits. As hard deposits build up over time in dental suction lines, they reduce the effective diameter of the suction lines. They also provide a rough surface onto which microbial growth can occur. To address hard deposits, periodic cleaning of suction lines using a product than can dissolve such deposits is needed. While mineral deposits could in theory be dissolved away using strong acids (such as HCl), these will cause corrosion of metal components in the suction system (such as butterfly valves and solenoids), as well as numerous other bystander reactions. Working with concentrated HCl would also pose significant work health and safety issues for staff because of its volatile nature (generating highly irritant fumes) and its ability to cause soft tissue injuries. As a result, suction system cleaners use mineral chelators, instead of strong acids, to dissolve mineral scale. These pose much less issues for OH&S and are less likely to cause corrosion of metal components (like valves) than strong acids. As they bind tightly to divalent and trivalent metal ions, they have a water softening action, which suppresses further formation of insoluble precipitates. Phosphonates are stable under the low pH conditions that are best for dissolving away mineral deposits. Phosphonates are used widely in water treatment processes including desalination and reverse

oral|hygiene

infection | CONTROL osmosis so their chemistry is well known. Phosphonates are the major active ingredient used in Eurosept Xtra Evac Cleaner® Weekly Concentrate, which is designed for removing hard deposits from suction lines. This product has a low pH (<2) which assists in breaking down mineral deposits and amphoteric surfactants to increase the contact of the solution with the walls of the tubing.

Removing soft deposits from suction lines icrobial biofilms form in dental suction lines for several reasons. First, the suction hoses are repeatedly contaminated with oral microorganisms. These have multiple origins, including from coolants and irrigant solutions, tap water, dental unit waterlines and the patient’s dental plaque, saliva and blood.25-27 Second, the suction lines are often wet. Flowing water provides a shear force along the walls of the lines. This provides an environment that is highly conducive to the growth and proliferation of microorganisms in a dense adherent biofilm. Field studies show that heavy microbial contamination of the dental suction lines extends from the dental chair to the suction unit and thereafter from the suction unit drain lines.28 Third, a generous supply of proteins and other nutrients from saliva and blood ensures the rapid growth of many types of microorganisms as well as numerous species within one type. As an indicator of high levels of blood exposure, direct evidence for high levels of blood being retained on the inner surface of suction tips after periodontal debridement has been provided using the Kastle-Meyer reagent test, in which a colour change to purple indicates the presence of fresh or dried blood.29 Typical organisms that have been isolated from dental suction systems are listed in Table 1. Levels of Gram negative bacteria in dental suction line biofilms can exceed 500,000 CFU per square cm. Similar issues have been found in medical suction systems used in hospitals, which have caused outbreaks of infection involving different opportunistic Gram-negative bacteria.30,31 An important pathogen found at high levels in dental suction lines is the Gram negative bacterium Pseudomonas aer-

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Table 1. Microorganisms isolated from biofilms in suction lines

Gram negative bacteria • Pseudomonads including P. aeruginosa, P. fluorescens and P. putida • Alcaligenes xylosoxidans • Aeromonas salmonicida • Acidovorax temperans • Burkholderia cepacian • Comamonas acidovorans • Novosphingobium subarctica • Serratia marcescens • Sphingomonas spp. including S. aerolata, S. paucimobilis and S. trueperi • Stenotrophomonas maltophilia Gram positive bacteria • Bacillus spp. • Streptococcus spp. including S. pneumoniae, S. salivarius and S. mitis • Staphylococcus spp. including S. aureus, S. epidermidis S. haemolyticus and S. warneri Fungi • Acremonium • Rhotodotorula • Cladosporium • Fusarium • Aurobasidum pullulans Data collated from multiple studies undertaken at Trinity College, Dublin, Ireland by M.A. Boyle and M.J. O’Donnell uginosa, which is able to outcompete many other bacteria. It grows well in wet regions and on PVC and medical tubing.32-35 This is particularly relevant during the COVID-19 pandemic, as forced shutdowns may result in dental chairs remaining unused or under-used for extended periods of time. P. aeruginosa and other pathogens are able to remain viable during periods when nutrient levels are low. The presence of Pseudomonads explains why suction line biofilms can be coloured green, yellow or brown.

Suction line odours reakdown of proteins from saliva and blood that contain amino acids with sulphur atoms results in the release of volatile sulphur compounds (VSCs), such as hydrogen sulphide (H2S), methyl mercaptan (CH3SH) and dimethyl sulphide [(CH3)2S]. These have a characteristic unpleasant odour.36,37 Such odours will provide an unsatisfactory environment for both patients

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infection | CONTROL and staff when they accumulate during periods when the dental clinic airconditioning is not operated or if the dental operatory is poorly ventilated.38 More of such odours will be noticed in the dental operatory when biofilm levels in the lumen (i.e. on the internal walls) of the suction tubing are high. When this problem is found, the likely causal factors (Table 2) should be explored. Using the correct product at sufficient frequency (at least once per day at the end of the day) will minimise biofilm formation. When odours are present when the suction is off, indicating that biofilm levels are high, more frequent treatment (e.g. twice daily until the problem resolves) would be appropriate. It is also important to note the problem of leakage from suction system hoses at their sites of attachment to the dental chair, caused by gradual loosening during use. One study of variations in microbial flora in dental suction lines reported the presence of some P. aeruginosa strains (such as serotype O:10, SpeI fingerprint group II) that seemed particularly well adapted to survive in dental suction systems and which may be particularly resistant to disinfection. In the situation reported, the suction lines had been disinfected after each clinical session (i.e. twice daily, Monday–Friday) with a phenolic disinfectant (PuliJet® from Cattani) in a process that took approximately 1 minute. This regular disinfection with Pulijet appeared to be ineffective at controlling bacterial contamination in the suction system. The very short contact time that the disinfectant had with the inside surfaces of the suction system (i.e. approximately 1 min) was also thought to be a contributory factor.24 Other studies also reinforce the point that dental suction systems become heavily contaminated during use and that conventional disinfection protocols may not be entirely effective at controlling this issue. Prolonged biofilm growth can lead to issues with the suction handpiece valves that are used to regulate suction strength either leaking or becoming stuck in one position. Leaks occur because extensive microbial biofilms on O-rings have caused these seals to perish. A stuck valve can be due to congealed blood, as well as corrosion of metal components.39

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Table 2. Factors that promote growth of biofilms in suction lines

Irregular/insufficient flushing with an appropriate antimicrobial solution • Frequency is too low • Volume of product used is too low • Exposure time for the product is too short • Product concentration is too low (incorrect dilution ratio, product expired, incorrect solvent used) • Tap water used for product dilution is hard Frequent surgical and periodontal debridement procedures where blood is generated, with insufficient flushing using water or saline at the end of the procedure Product compositions for disinfection rinciples for microbial control of biofilms in suction lines have parallels to those used for dental unit waterlines, particularly flushing and periodic aggressive chemical treatments to disrupt biofilms.40-42 An important distinction is that the nutrient environment is rich in the suction lines, resulting in more vigorous growth of microorganisms. The microbial diversity is greater, with bacteria, fungi and amoeba being present. This is why active ingredients with broad spectrum disinfecting actions are needed for treating dental suction lines and why dental suction lines must be disinfected regularly.43,44 It is not practical to detach suction hoses (for thermal disinfection) either after each patient or on a daily basis, hence aspiration of chemical disinfectants on a regular basis is needed. Most dental chair manufacturers suggest this be done at least once daily, at the end of the working day. Field studies reveal that compliance with this recommended frequency of suction system disinfection varies widely.45 Products used for breaking down the matrix of biofilms and killing microorganisms will typically contain low foaming surfactants, as well as disinfectants and fragrances, with the latter providing a deodorising action. Using enzymes at neutral pH is a highly effective strategy for breaking down complex biofilms. Eurosept Xtra Evac Cleaner® Daily is an example of an enzymatic

cleaning concentrate, designed for daily cleaning and care of dental suction systems. This product is pH neutral and contains non-ionic low-foaming surfactants. These ensure maximal penetration of the enzymes into soft deposits of organic matter such as residues of blood, saliva and biofilms. Chemical compatibility with suction system components and amalgam separators is another important consideration. Use of strong oxidants could lead to powdery corrosion of aluminium components such as manually operated suction butterfly control valves and suction tip connectors following prolonged use. These deposits of aluminium oxide can impair the action of the control valves and impair proper intake of air. This will not occur if the butterfly control valves and suction tip connectors are made from high-quality, acid-resistant steel as that will resist corrosion by strong oxidants such as hydrogen peroxide.46 A variety of factors can contribute to failure of suction line disinfection in the long term, including human errors (not following use protocols; incorrect product selection; incorrect dilution), as well as corrosion and deterioration of the suction lines and suction equipment. Disinfectants used in suction cleaners designed for daily use will need a broad antimicrobial spectrum. When considering possible candidates, chemical inactivation, optimal pH, interactions with proteins and ecological effects in water systems are parameters to consider,

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infection | CONTROL as well as the likelihood of corrosion. Keeping close to a neutral pH is desirable for material compatibility. Typically, suction cleaners are designed for both being used in the suction system and also being poured into the spittoon, at the same concentration. Follow the manufacturer’s instructions and check whether the product is low foaming before attempting to treat a spittoon.

Correct product handling and usage uction cleaners can combine the two functions of reducing biofilm and dealing with mineralised deposits, and various manufacturers have developed protocols around optimising both functions. Some have taken the approach of a frequent-use product where microbial

References 1. Micik RE, Miller RL, Mazzarella MA, Ryge G. Studies on dental aerobiology, I: bacterial aerosols generated during dental procedures. J Dent Res. 1969; 48: 49-56. 2. Bentley CD et al. Evaluating spatter and aerosol contamination during dental procedures. J Am Dent. Assoc. 1994; 125: 579-584. 3. Bennett AM et al. Microbial aerosols in general dental practice. Br Dent J. 2000; 189: 664-667. 4. Leggat PA, Kedjarune U. Bacterial aerosols in the dental clinic: a review. Int Dent J. 2001; 51: 39-44 5. Jacks ME. A laboratory comparison of evacuation devices on aerosol reduction. J Dent Hyg. 2002; 76: 202-206. 6. Harrel SK, Molinari J. Aerosols and splatter in dentistry: A brief review of the literature and infection control implications. J Am Dent Assoc. 2004; 135, 429-437. 7. Timmerman MF et al. Atmospheric contamination during ultrasonic scaling. J Clin Periodontol 2004; 31: 458-462. 8. Harrel S K. Airborne spread of disease – the implications for dentistry. J Calif Dent Assoc. 2004; 32: 901-906. 9. Dahlke WO et al. Evaluation of the spatter-reduction effectiveness of two dry-field isolation techniques. JADA. 2012; 143: 1199-1204. 10. Zemouri C et al. A scoping review on bio-aerosols in healthcare and the dental environment. PLoS ONE 2017; 12(5), e0178007. 11. Kobza J et al. Do exposures to aerosols pose a risk to dental professionals? Occup Med. 2018; 68:454-458. 12. Liu MH et al. Removal efficiency of central vacuum system and protective masks to suspended particles from dental treatment. PLoS ONE 2019; 14: e0225644. 13. Meethill AP et al. Sources of SARS-CoV-2 and other microorganisms in dental aerosols. J Dent Res 2021; 1-7. DOI: 10.1177/00220345211015948 14. Allison JR et al. Evaluating aerosol and splatter following dental procedures: addressing new challenges for oral health care and rehabilitation. J Oral Rehabil. 2021; 48:61-72. 15. Holliday R et al. Evaluating contaminated dental aerosol and splatter in an open plan clinic environment: Implications for the COVID-19 pandemic. J Dent. 2021; 105: 103565. 16. ISO 7494-2:2015 Dentistry. Dental units. Air, water, suction and wastewater systems. 17. Harrel S K, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. J Am Dent Assoc 2004; 135: 429-437. 18. Matys J, Grzech-Lesniak K. Dental aerosol as a hazard risk for dental workers. Materials 2020; 13: 5109. 19. Balanta-Melo J et al. Rubber dam isolation and highvolume suction reduce ultrafine dental aerosol particles: an experiment in a simulated patient. Appl Sci. 2020; 10: 6345. 20. Holloman JL et al. Comparison of suction device with saliva ejector for aerosol and spatter reduction during ultrasonic scaling. J Am Dent Assn 2015:146: 27-33. 21. Watson CM, Whitehouse RL. Possibility of cross-contamination between dental patients by means of the saliva ejector. J Am Dent Assoc. 1993; 124: 77-80. 22. Mann GL et al. Backflow in low-volume suction lines: the impact of pressure changes. J Am Dent Assoc 1996; 127: 611-615. 23. Barbeau J et al. Cross contamination potential of saliva ejectors used in dentistry. J Hosp Infect. 1998; 40: 3030311. 24. O’Donnell MJ et al. Bacterial contamination of dental chair units in a modern dental hospital caused by leakage from suction system hoses containing extensive biofilm. J Hosp Infect. 2005; 59: 348-360.

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25. Wirthlin MR et al. Formation and decontamination of biofilms in dental unit waterlines. J Periodontol 2003; 74: 1595-1609. 26. Szymanska J et al. Microbial contamination of dental unit waterlines. Ann Agric Environ Med. 2008; 15: 173-179. 27. Spagnolo AM et al. Microbial contamination of dental unit waterlines and potential risk of infection: a narrative review. Pathogens 2020; 9: 651. 28. Conte M et al. Microbiological contamination of compressed air used in dentistry: an investigation. J Env Health 2001; 64 :15-26. 29. Edmunds LM, Rawlinson A. The effect of cleaning on blood contamination in the dental surgery following periodontal procedures. Aust Dent J. 1998; 43: 349-353. 30. Blenkharn JIl, Hughes VM. Suction apparatus and hospital infection due to multiply-resistant Klebsiella aerogenes. J Hosp Infect 1982; 3: 173-178. 31. Rubbo SD et al. Source of Pseudomonas aeruginosa infection in premature infants. J Hyg 1966; 64: 121-128. 32. Stoodley P et al. Biofilms as complex differentiated communities. Annu Rev Microbiol. 2002; 56: 187-209. 33. Mendis N et al. Comparison of virulence properties of Pseudomonas aeruginosa exposed to water and grown in rich broth. Can J Microbiol. 2014; 60: 777-781. 34. Rozej A et al. Structure and microbial diversity of biofilms on different pipe materials of a model drinking water distribution systems. World J Microbiol Biotechnol. 2015; 31: 37-47. 35. Ammann CG et al. Pseudomonas aeruginosa outcompetes other bacteria in the manifestation and maintenance of a biofilm in polyvinylchloride tubing as used in dental devices. Arch Microbiol. 2016; 198: 389-391. 36. Tonzetich J. Direct gas chromatographic analysis of sulphur compounds in mouth air. Arch Oral Biol 1971; 16: 587–597. 37. Yaegaki K, Sanada K. Volatile sulfur compounds in mouth air from clinically healthy subjects with and without periodontal disease. J Periodont Res 1992; 21: 434-439. 38. Smith AJ. The devil is in the validation and design; managing the risk from opportunistic pathogens in the dental unit. J Hosp Infect. 2021; 114: 61-62. 39. Boyle MA et al. Overcoming the problem of residual microbial contamination in dental suction units left by conventional disinfection using novel single component suction handpieces in combination with automated flood disinfection. J Dent. 2015; 43: 1268-1279. 40. Fux CA et al. Survival strategies of infectious biofilms. Trends Microbiol. 2005; 13: 34-40. 41. Walker JT, Marsh PD. Microbial biofilm formation in DUWS and their control using disinfectants. J Dent. 2007; 35: 721-730. 42. Garg SK et al. Dental unit waterline management: Historical perspectives and current trends. J Investig Clin Dent. 2012; 3: 247-252. 43. Costa D et al. Planktonic free-living amoebae susceptibility to dental unit waterlines disinfectants. Pathog Dis. 2017; 75: ftx099. 44. Yoon HY, Lee SY. Susceptibility of bacteria isolated from dental unit waterlines to disinfecting chemical agents. J Gen Appl Microbiol. 2019; 64: 269-275. 45. Watson CM, Whitehouse RL. Possibility of cross-contamination between dental patients by means of the saliva ejector. J Am Dent Assn 1993; 124: 77-80. 46. O’Donnell MJ et al. Optimisation of the long-term efficacy of dental chair waterline disinfection by the identification and rectification of factors associated with waterline disinfection failure. J Dent. 2007; 35: 438-451.

control is paramount and a periodic use product (e.g. twice weekly) formulated to dissolve mineral deposits. For efficient transport, products may be shipped as concentrates which are then diluted, typically with ordinary tap water. The final mixture is then run through the suction system and/or poured down the spittoon.

Conclusions ental suction is essential for safe dental practice and HVE is a critical component of infection control work practices that remove aerosols and reduce their spread. The COVID-19 pandemic has made dental practices more aware of the importance of proper HVE. For proper performance, dental suction lines need regular attention to remove both hard deposits and microbial biofilms. The products used must remove these deposits while not causing corrosion or other forms of deterioration. Well designed products used in the right way will also ensure that problems such as the generation of odours do not occur when the dental chair is not in use.

About the author Emeritus Professor Laurence J. Walsh AO is a specialist in special needs dentistry who is based in Brisbane, where he served for 36 years on the academic staff of the University of Queensland School of Dentistry, including 21 years as Professor of Dental Science and 10 years as the Head of School. Since retiring in December 2020, Laurie has remained active in hands-on bench research work, as well as in supervising over 15 research students at UQ who work in advanced technologies and biomaterials and in clinical microbiology. Laurie has served as Chief Examiner in Microbiology for the RACDS for 21 years and as the Editor of the ADA Infection Control Guidelines for 12 years. His published research work includes over 330 journal papers, with a citation count of over 15,400 citations in the literature. Laurie holds patents in 7 families of dental technologies. He is currently ranked in the top 0.25% of world scientists. Laurie was made an Officer of the Order of Australia in January 2018 and a life member of ADAQ in 2020 in recognition of his contributions to dentistry.

September/October 2021

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CPD

Why who made your mask matters

hen COVID-19 created an unprecedented demand for personal protective equipment (PPE), many countries were caught off guard. Without sufficient stockpiles of items such as masks, gowns and gloves, shortages developed in these disposable items. As demand began to surpass available supply from reputable manufacturers, clinicians tried to source these from wherever they could. Around the world, some companies were eager to profit from the increased demand for consumer level masks, as well as masks for health care. It is fair to say that some of these manufacturers had no medical device manufacturing experience and no knowledge of the regulatory requirements that are in

28 oral|hygiene

September/October 2021

infection | CONTROL

“Many masks are tested in the USA (at Nelson Labs in Utah), however on-shore mask testing was developed in Australia in 2020 so performance testing is now typically done within Australia...” technologies that are used. It needs high-quality raw materials, state-of-the art manufacturing techniques and stringent quality controls, so that the masks meet the regulatory requirements. A face mask meets the TGA definition of a medical device when the following claims are made. Either the mask is to be used for the prevention of the transmission of disease between people, or the mask is intended for use in health services. According to the TGA, if the manufacturer’s labelling, advertising or documentation contains such claims above, the mask is considered to be a medical device and it must be included in the Australian Register of Therapeutic Goods (ARTG). Masks for use in dentistry must be included in the ARTG before being imported into or supplied in Australia, exported from Australia, or advertised in Australia. Masks that are non-sterile are regulated as Class I medical devices, however, the TGA has put in place more rigour and a validation process for masks included in the ARTG, including an audit of the evidence held by the manufacturer to demonstrate the performance and the quality of the mask.

Australian standard for medical face masks S 4381:2015 Single-use face masks for use in health care classifies masks into three levels (1, 2, 3) based on their resistance to fluid penetration. Resistance to fluid penetration

September/October 2021

is measured using synthetic blood at pressures of 80, 120 or 160mm Hg. Note that consumer masks are not required to have fluid resistance, but despite this they can be used by the general public in non-healthcare settings to reduce the risk of the spread of infections, particularly in epidemic or pandemic situations. For healthcare settings, level 1 surgical masks have low fluid splash resistance (80 mm Hg) and are used for procedures where no splash of body fluids is expected (e.g. denture prosthetics). Masks with medium level fluid splash resistance (120 mm Hg) are used for routine procedures in dentistry where some splash of body fluids is expected, while masks with high level fluid splash resistance (160 mm Hg) are designed for settings where arterial squirting to the face may occur (e.g. paramedics, orthopaedic surgery, cardiac surgery, limb amputations, etc). The test methods are ASTM F2101-14 or EN 14683:2014. Many masks are tested in the USA (at Nelson Labs in Utah), however on-shore mask testing was developed in Australia in 2020 so performance testing is now typically done within Australia. Bacterial filtration efficiency (BFE) measures how well a mask filters out bacteria. AS 4381 specifies testing with a droplet size of 3.0 microns containing Staphylococcus aureus (average size 0.6-0.8 microns). A minimum 95% filtration rate is required for level 1 masks. Level 2 and level 3 masks must have bacterial filtration rates greater than 98%.

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infection | CONTROL

AS 4381 does not provide a requirement for particle filtration efficiency (PFE) (e.g. for particles from 0.1-0.3 microns) as surgical masks are primarily designed to keep cross contamination between the health care worker and the patient to a minimum. The AS 4381 standard directs those clinical staff who need respiratory protection to the two Australian standards that apply to respirators, especially AS/NZS 1716:2012 Respiratory

“Medicom developed its medical mask expertise by working in close collaboration with the healthcare professionals who wear them. By investing in ongoing research and development, premium raw materials and state-of-the art machinery, the company continues to produce innovative, premium-quality masks...”

protective devices (Guidance on the selection, use and maintenance of respirators is given in AS/NZS 1715: 2009 Selection, use and maintenance of respiratory protective equipment). The Pressure Differential (Delta P) measures air flow resistance and so provides an objective measure of breathability. The test method is described in EN 14683:2014. Delta P is measured in units of mm H2O/cm2. The lower the value, the more breathable the mask is. Delta P for Level 1 masks must be less than 4.0 and for level 2 and 3 masks it must be less than 5.0.

30 oral|hygiene

When you wear masks during the whole day, comfort matters eputable medical mask manufacturers have a vested interest in maintaining their reputation for providing masks that are comfortable to wear during the working day in clinic. This is why high ratings for breathability and comfort are important. Medicom have been manufacturing masks and other items of PPE for healthcare for over 33 years and has the know-how regarding surgical masks that provide reliable protection, as well as exceptional breathability and comfort, even for those with sensitive skin. Medicom developed its medical mask expertise by working in close collaboration with the healthcare professionals who wear them. By investing in ongoing research and development, premium raw materials and state-of-the art machinery, the company continues to produce innovative, premium-quality masks that meet the needs and preferences of those who wear them. The Medicom SAFE+MASK PREMIER PLUS earloop mask is well-suited to routine use in dentistry. It has level 2 fluid resistance. The earloops are soft and strong and ample in length, so there is less pulling needed. The nosepiece is readily adjusted for achieving a comfortable fit to the nose.

Be sure you are wearing your mask properly surgical mask can only protect effectively if it is worn correctly. That means there should be no gaps along the sides of the mask between the mask and the face and that the mask should extend from the bridge of the nose to the chin. It is critical that the mask covers not only the mouth, but also the nose. To ensure adequate coverage of the nose, masks should not be worn below or at the tip of the nose.

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ith the ongoing threat of the COVID-19 pandemic, patients continue to be reluctant to visit dental clinics. Over 10% of patients - both adults and children - have delayed health care, including dental care, despite admitting the need for care. Patient communication is key to alleviating the fears that keep patients from returning to your dental practice.

32 oral|hygiene

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Co., LLC, its affiliates or related companies, unless otherwise All company noted. and product names are trademark Anitopen holethe pattern that promotes water flow throughout the cassette •affiliates Anitopen hole pattern that promotes water flow th Because ••when comes perfect fit,system Hu-Friedy is right. Because toAll the perfect fit, Hu-Friedy isofjust right. All company andjust product names arereduces trademarks of Hu-Friedy Mfg. Co., LLC, its when orcomes related companies, unless otherwise noted. company and are trademarks Hu-Friedy Co., LLC Color-coded silicone rail significantly instrument contact •when Anitto open hole pattern promotes water flow throughout the cassette •when An open hole pattern that promotes water flow throughout the casse Compared tothat other leading scaler Data on file. Available upon request. 1)product Compared to other leading scaler Mfg. designs. D Because comes to 1)the perfect fit, that Hu-Friedy isdesigns. just right. 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HFL-482AUS/1220 • Color-coded silicone rail system that reduces instrument contact and allows WHY DENTISTS LOVE STAINLESS STEELprotecting PEDO CROWNS: WHY DENTISTS LOVE OUR STAINLESS STEEL PEDO CROWNS: WHY DENTISTS STAINLESS STEEL PEDOwhile CROWNS: forLOVE more water flow while protecting the instruments during reproce for moreOUR water flowSTAINLESS while the instruments during reprocessing forOUR more water flow protecting the instrume WHY DENTISTS LOVE OUR STEEL PEDO CROWNS: • Ideal andfor mesio-distal widthflow • height Easy-to-use, ergonomic latch thatprotecting allows forthe one-handed opening more water while instruments during reprocessing • Ideal height and mesio-distal width • Easy-to-use, ergonomic latch that allows for one-handed opening All company and product names are that trademarks of Hu-Friedy Mfg.one-h Co., LLC •• Ideal height and mesio-distal width • Ideal height and mesio-distal width • Easy-to-use, ergonomic latch that allows for one-handed opening • Easy-to-use, ergonomic latch allows for ™ unless otherwise Pre-trimmed pre-crimped for simple placement All company and product trademarks ofone-handed Hu-Friedy LLC, its affiliatesInfinity or related companies, All company noted.scaler anddesigns. product are trademark Performing at your best means having confidence in youMfg. do.Co., Experience Series Cassettes, and improve • Ideal height and mesio-distal width • and Easy-to-use, ergonomic latchnames thatare allows forwhat opening 1) Compared to other leading Datanames on file. 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To learn more about how IMS can enhance VISIT USCo., ONLINE AT HU-FRIEDY.COM/PerfectFit Hu-Friedy Mfg. LLC, 1666 how E. Touhy Ave., Desenhance Plaines, IL 60018 | Hu-Friedy.com To learn more about IMS your practice visit Hu-Friedy.com/Infinity VISIT US ONLINE AT HU-FRIEDY.COM/PerfectFit ToHu-Fried learn more about howcan IMS can enhance ©2016 y Mfg. Co., LLC.ONLINE All rights reserved. All company and product names are trademarks of Hu-Friedy Mfg. Co., LLC, VISIT US AT HU-FRIEDY.COM/PerfectFit your practice visit Hu-Friedy.com/Infinity ©2016 Hu-Fried y Mfg. Co., LLC. All rights reserved. its affiliates or related companies, unless otherwise noted.member of ©2017 Hu-Friedy Mfg. Co., LLC. Allis rights reserved. Hu-Friedy now a proud your practice visit Hu-Friedy.com/Infinity ©2016 Hu-Fried y Mfg. Co., LLC. All rights reserved. Hu-Friedy is now a proud member of ©2021 Hu-Friedy Co.,AllLLC. rights reserved. ©2017 Hu-Friedy Mfg.Mfg. Co., LLC. rightsAll reserved.

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infection | CONTROL Patient arrival and the practice environment e prepared to answer the most common questions patients might ask: At what stages are masks a requirement in the practice? Why do your staff wear masks? Is there space to socially distance in the waiting room? Can patients bring someone with them or do they need to arrive alone? Under what situations can parents and caregivers be in the treatment room?

B •

• • • • Even if your dental practice has a designated Infection Prevention Coordinator (IPC), consider allocating time for your team to review requirements and any changes and then collectively update your patient communication plan. This will allow your entire team to share the most current information with patients and walk them through your processes, while also knowing they can come to the IPC with any questions they aren’t sure how to answer.

Infection control ost patients don’t know much about infection control in dentistry. Encourage your team to initiate a conversation and proactively answer questions

Talk to patients about each step in the process our patients need to be comfortable with every step your practice takes to ensure their safety. If they don’t trust you, you might lose them as patients altogether. Walk your patients through reprocessing, cleaning and sterilisation, room turn-over and the necessary PPE your staff members wear during cleanings and procedures. Offer a tour of your sterilisation room so they can see the stages of instrument reprocessing before their visit. If you use instrument cassettes, explain their advantages for organisation and patient safety. When it comes to helping patients become more comfortable with your safety measures and infection control practices, there really is no such thing as too much information.

ou should be able to give patients an overview of your process to make them feel more comfortable. This includes areas like:

34 oral|hygiene

f you use an instrument management system (IMS), visually this can look much more reassuring to patients than a collection of loose instruments on a tray. Plus, if the instruments are neatly organized and standardised, treatment will proceed more smoothly, which helps reduce patient anxiety. Encourage your team to show patients the IMS™ Cassettes you use and explain how they work, which can answer questions patients may not know they have. Questions include: • What does your practice do with instruments after they’ve been used on patients? • Why do you clean and sterilise instruments between each patient? • How does your practice sterilise the instruments? • How do patients know the instruments are sterile when they are used? • What does your practice do with items you can’t sterilise using steam?

Surface disinfection astly, be ready to answer questions about how the environmental surfaces in your practice are cleaned and disinfected. During the course of treatment, lots of surfaces can potentially be contaminated from direct spray or splatter, which could lead to these types of questions from patients: • Why are some surfaces in the practice covered in plastic barriers? • How will patients know the surfaces not covered by plastic are clean? • What products does your clinic use to treat such surfaces? It’s perfectly normal for patients to experience some fear or concern about their dental visit while COVID-19 is still an issue in the community, but it shouldn’t stand in the way of them getting the quality of care that they need. You’ve done the work to safeguard your practice and implement best practice protocols to prevent infection and keep patients safe. Now you just have to make sure you can proactively have the conversations with patients to make them feel more comfortable about coming into the practice - and leaving with a healthier smile.

Provide detailed information about your protocols

Instrument sterilisation

about the actions your practice takes to protect patients, which can be an opportunity to introduce the role of the Infection Control Coordinator. Questions to pre-emptively answer include: • What is infection control and why this is important for health and safety when attending for dental care? • What steps does your clinic take for infection control? • How can patients know that the clinic is doing everything it can for infection control? • What disinfectants does your clinic use? • What should patients do if they become ill just before their appointment? • What are the procedures for clinical staff to call in if they’re sick?

September/October 2021

YOUYOU REQUIRE MAXIMUM EFFICIENCY. YOU REQUIRE MAXIMUM EFFIC REQUIRE MAXIMUM EFFICIENCY. YOUYOU DEMAND COMPLETE ORGANIZATION. YOU DEMAND COMPLETE DEMAND COMPLETE ORGANIZATION. HUFRIEDYGROUP INTRODUCES HUFRIEDYG YOUYOU NEED ENSURED SAFETY. HUFRIEDYGROUP YOU NEED ENSURED S NEED ENSURED SAFETY. INTRODUCES ™ ™ YOU DESERVE INFINITE CONFIDENCE. YOU DESERVE HUFRIEDYGROUP INTRODUCES YOU DESERVE INFINITE CONFIDENCE. HUFRIEDYG HUFRIEDYGROUP INTRODUCES

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