Dental Love In the Time of Covid-19

Dentistry and dental hygiene care will most certainly be changing as we all learn to navigate the “new normal” that will change our dental lives. We most certainly want to keep our dental patients and dental families safe as we start heading back to work. Our office- Green City Dental plans to re-open the week of May 18th. I am so excited to see all my patients and share all my dental love and covid-19 information with them. Today’s post is to review all the things we do in our biological office that has kept you safe and the new upgrades to continue keeping you safe in this time of Covid-19.

Dentistry has been dealing with bacteria, fungi, parasites and viruses forever! This is nothing new to us. In addition to Covid, we have previously dealt with colds, Hepatitis virusus, cold sores, Epstein-Barr virus, all the Human papilloma viruses, HIV that causes AIDS, Cytomegalovirus, as well as SARS, MERS, H1N1, Influenza and Bird Flu. True that some of these are bloodborne infections (acquired by coming in contact with blood) while others are aerosol driven. Viruses are part of my dental world.

History Repeating Itself Again and Again

So many hygienists are wondering how they can possibly go back to work safely with this new virus and all the aerosols we make when drilling and ultrasonicing (power scaling) teeth.

Way back in the early first year of my career (very long ago), I first learned about AIDS and HIV at a course I attended in Miami. I came back to work a different woman, wondering if I too could/would continue in my chosen field. At that point in my career I did not love hygiene, nor the dental office I worked in so the questions were even more important. In the early-mid 80’s we did not wear gloves or masks, and we “disinfected everything” with rubbing alcohol and cold sterile. (I saw a fellow dentist contract a herpes virus in his right index finger, put him out of work for weeks. No gloves. I always wondered how often that virus reappeared there. Right index fingers are important for right handed dentists.)

On my return from that course, I knew I needed to wear gloves with every patient but dental companies did not sell gloves by the case. The only gloves were the doctor’s surgical gloves at $7.00 a pair. Not something I could change with every patient. I would “sneak” one pair a day and wash them with every patient. Not perfect certainly, and by the end of the day they were very sticky. I continued to wear gloves and added a face mask too. Patients would look at me and whisper to the dental assistant “is she sick?” No, they explained, “she’s just paranoid”. Maybe I am. I prefer to think of it as cautious of all the bloodborne pathogens. By the mid late 1980’s dentistry finally had gloves by the case and lots of face masks. It became the standard of care. And high time, I say, since we knew about all those other diseases and viral infection even before HIV Aids. HIV pushed us to be better. Now Corona Viruses will give us the next big shove to improve our profession. Time to address the aerosol bioburden. I say hooray!

That Teeny Tiny Microbial World

Viruses are nasty buggers. Or maybe not. We already house over 380 TRILLION of them in our bodies.

Viruses are actually an important part of our microbiome. They have their own ecosystem term called a human virome. Viruses are on and in every part of our bodies. We cannot escape them and nor should we. They are part of that microbial world we need to keep us healthy and alive. Viruses are inside bacteria and help keep things in homeostasis. They can kill bacteria so they are vital to our health and wellbeing, they are an important part of our immune system. In order for our immune systems to function we need all the players, viruses included.

Viruses are teeny tiny- between .02 to .4 micrometers across. They are surrounded by a coat of either protein, lipid(fat) or glycoprotein. They need another cell to live in – a host cell. Viruses are essentially parasites. Once inside the body, the protein covering on the outside feels and recognizes the proper host cell it needs to live in. This can be both to our good or to our detriment. It attaches to the cell membrane and can either dissolve right into the cell or it injects itself into the cell. Once there, it may lie dormant for years or start replicating immediately. When it has replicated itself it then either breaks open the cell thus destroying it, or it punches out and breaks away. Our body needs a healthy microbiome and thus a healthy virome in order to keep everything in symbiosis or health as opposed to dysbiosis or infection.

Viruses infect our mucus membranes (our noses and upper respiratory tracts). When we are infected and cough or sneeze we spread the virus. Current science says we contract the Sar-CoV-2 virus via large respiratory droplets rather than smaller aerosol. Droplets are heavy and fall to the ground, not traveling far- maybe six feet. The problems arise when we cough, sneeze and have dental procedures. We propel these particles even farther, potentially upwards of 20 feet. In these aerosols, it can stay suspended for up to three hours. Therein lies the problem and we will return to the solutions shortly.

Our bodies want us to be healthy so should viruses invade you the first thing you may notice is a fever.

The heat from fever cooks that virus, destroying the protein covering around the virus to keep it from replicating. Fever is part of our immune system hard at work keeping us healthy. Of course a too high fever needs to be addressed but we need to let our bodies do what they do best and fight to reduce the reproduction of the “bad” viruses. So, reducing a slight fever may be counterproductive to our healing.

A slight digression but we needed to know whom we are fighting and why. Not all viruses and bacteria are bad. Back to dental care …

Up Your Game

Our dental goal is to help you get, stay and/or be healthier. It starts with a healthy mouth. The oral microbiome is full of the same bacteria, viruses and fungi that infect other parts of you. We are not ever going to make it sterile but my goal, as your oral health and wellness coach and chief cheerleader, is to reduce and improve this world so it is made up of healthy microbes. That way, the microbes floating around your body are the “good guys”. Not the ones creating a low grade chronic infection for years and years.

If you have bleedy, leaky gums then you have an INFECTION and that then allows these pathogens to invade your gut by swallowing them, your lungs through inhalation of them, and of course via your blood stream every time you chew, brush or get a dental cleaning. These pathogens destroy everything in their pathway. If your goal is to be healthy then it is time to “up your dental game” and start taking better care of you. Let’s start with your mouth.

Pretend your body is the most expensive car ever owned. Beautiful, sleek and purrs like a kitten. Would you put cheap gas in it? Would you neglect it? Would you use the wrong oil? Would you run it until you were out of gas? Would you be careless? NO, because you just invested a lot of money on this beautiful automobile. Think of your body in this same light. This wonderful body of yours needs you to take care of it just like it is an exquisite machine (which it is).

Eat good healthy clean food, nourish it with vitamins and minerals, exercise daily, deep restful sleep, sunshine, stretch, and relaxation. Cheap food is processed food, devoid of vitamins, minerals and other nutrients, and of course, full of sugar. Vitamin D3 is VITAL to being healthy. Vitamin D deficiency has been proven to contribute to acute respiratory distress syndrome. GET outside and soak up that glorious sunshine. Up your health game.

Every Breath You Take

Breathing correctly is also vital to health. It may be even more vital during this viral outbreak. Nasal breathing is the best way to breathe because your nose filters the air, purifies and disinfects the air by releasing nitric oxide. When you mouth breathe the air and everything in it goes straight to the lungs – no protection, no filtration. If you do happen to walk through a corona virus laden aerosol plume mine field you will have a better chance of staying healthy by nasal breathing.

Let’s talk masks. Masks prevent you from spreading droplet infection if you are sick. This is a hot topic and if you feel safer wearing a mask here are tips to do that CORRECTLY.

#1. Put it over your nose and mouth. Not under your nose, and need I say it won’t do any good at all if it does not cover your mouth. Handle it by the ear loops. Cinch it down on your nose. close off any gaps.

#2. Once you put it on your face- DO NOT touch it.

#3. When you remove- do so by the ear loops. And dispose of it properly. We consider them hazardous waste.

#4. Breathe through your nose even under the mask. Most folks start mouth breathing under masks because it is harder to breathe, so the mouth pops open. You are way better off nasal breathing.

#4. Wash your hands before and after wearing a mask.

As part of my new improved hygiene protocols, I will be testing all my patients’ nitric oxide (NO) levels. This is an easy chairside dipstick test. We just gather a small load of saliva and dip the test strip in it to see how high your nitric oxide level is. The higher the better to help disinfect your paranasal sinuses and keep the air you breathe clean and healthy. As we age we produce less and less nitric oxide and this is an important piece of keeping you well. NO production starts on the back on the tongue as well so good oral hygiene vital to utilizing all your nitric oxide properly.

Breathe through your diaphragm. Shoulders should never rinse up when breathing. EVEN when exercising. Yes, I know, difficult but so much healthier for you. That’s a work in progress even for me.

Every Swish You Make

Research is discussing the impact viral load has with disease severity. One study reported that those with severe COVID -19 symptoms had a 60 time higher viral load in their nasopharyngeal swabs verse those with mild symptoms. We know there are viruses in the mouth and pharynx and Dr Bruce Davidson a pulmonary doctor and researcher in Seattle recommends a preprocedural rinse for 60 seconds to reduce the oral viral biofilm load and basically disinfecting the throat.

The other thing I learned from Dr Davidson is most people aquire the virus while sleeping. They harbor the virus in their nose and throat and it slides down below your voice box. Then, while sleeping you aspirate them into your lungs. Aspiration is also how most pneumonia happens. Getting the corona virus infection depends on your total systemic health and the number of viruses in your system. So, proper breathing and swallowing even when sleeping, as well as proper oral hygiene are even more important.

As part of our new improvements we are also incorporating preprocedural rinsing with every appointment. We will be recommending a 60 second swish with either a 1.5% hydrogen peroxide or ozone water. Ozone is one of my favorite topics because it is so effective. Ozone gas kills bacteria, fungi, parasites and viruses almost on contact. More on ozone shortly. Along with a swish, you need to gargle to help disinfect those tonsils.

The Nose Knows

At the start of the hygiene appointment we will review oral hygiene protocols to reduce the bacterial bioburden. The bioburden in your mouth is the source of the pathogens that then get propelled into the aerosol droplets. Reducing the pathogens in the aerosols are the key to a healthy dental appointment and even better, a heathy dental office. This is the key to keeping all of us healthier.

We address how to maintain a healthy mouth and NOSE. Yes, nasal hygiene is a thing. It is critical to your health and well being and we just don’t even think about it.

I want to do an entire post called “the Nose Know”s but it is such a great title I had to drop it in here first. Your nose cannot work if your sinuses are all full of junk. Your nose needs to be washed and cleaned out daily otherwise you resort to mouth breathing which you now know is unhealthy breathing.

At Green City we will also do nasal hygiene to clear your sinuses. I like the product Xlear– they have nasal sprays, and a nasal wash too. If you are so inclined, please get yourself some and start every morning and end every evening with two squirts in each nostril. Then blow your nose. There are other sinus washes that use saline so you do what you feel comfortable doing.

Seeing the Bioburden is Believing

As many of you know, at Green City Dental we use a phase contrast microscope to see the bacterial biofilm in action on the microscope screen with every dental hygiene appointment. This gives us an idea of what the gum disease bacterial level is doing. In addition to testing the gum disease pathogens I have also been testing the bacterial load for tooth decay on our Carifree meter. Now, in addition to those previous tests we have new salivary testing to look more closely at all these pathogens for both gum disease and tooth decay, as well as the viral load and genetic potential for future oral disease.

The goal is test, treat , retest until the tests come back negative. The infection in your mouth does not stay just in your mouth and gums. It is a sign of inflammation and infection. Gum disease and tooth decay DO NOT hurt UNTIL the final stages. You may not know you have any problems when in fact there is a raging infection that affects not only your mouth but your lungs and even more, the entire immune system. In this time of the SARS Co-19 virus, we want to ensure that every part of you is healthy and ready to fight the virus because it is so highly contagious.

Treating oral disease means working with the hygienist to find the right tools and techniques to reduce the pathogenic biofilm living in the mouth. It also means looking deeper at the true cause of the disease. There are so many components to look at: is it nutritional/gut dysbiosis/leaky gut/ vitamin or mineral deficiencies/sleep apnea/airway issues/smoking- cigarettes or cannibis/lifestyle/genetics?? Find the root cause, don’t just treat symptoms. We may need to include other professionals to help sleuth the underlying causes and help correct them. Bleeding leaky weepy gums means our house is on fire and needs a 911 call to all the experts. Our immune systems need help in healing.

Something in the Air We Breathe

You may have heard a lot about aerosols on the news as of late. How, you might ask is dentistry and dental hygiene going to operate since we, the dental profession create and generate all manner of aerosols. We at Green City Dental have tools and safe protocols that we have used for many years, especially when doing safe mercury removal. Mercury is one of the most toxic elements on earth and should always be removed using the SMART protocols. We can proudly say we have your safety in mind and want a patient-centered office that does keeps us all safe. We are already there to provide you with quality centered totally prepared dental care.

I have included a list of the things we do and some exciting new things we’re adding to make your dental health care even more complete and safe.

#1. Ozonated water. All our dental units use fresh ozonated water. Ozone kills bacteria, fungi, parasites and viruses. This water kills the virus within 20 seconds. Ozone kills viruses by dissolving that lipid layer and stopping their reproduction cycle. It also breaks down the cell walls of the bacteria and fungi. The fancy word is cell lysis.

Ozone water gradually becomes plain old water if left alone for a few hours. Ozone water can be used to disinfect surfaces, vegetables, hands, gums, teeth, you name it! It keeps our waterlines clean and bacteria free, and disinfects the mouth as we work.

Gentle and natural. And did I mention safe? As long as you don’t get a lung full, you are totally safe, and we will use our high volume suctions any time ozone is near your mouth to ensure your safety.

During the dental hygiene appointment, I have traditionally polished first to reduce the plaque biofilm level, and then used my piezo power scaling tool with ozone water to do an initial debridement of the tartar and plaque biofilm below the gumline. Then, I have often used ozone oil on my hand scalers to fine tune and finish the tartar removal. Disinfection, and reduction of that bioburden helps to jump start your healing.

At the end of the appointment, we will offer you one more round of our delicious ozone water to do a final 60 swish and gargle an swallow.

#2.The only change I will make is to use the tongue cleaner first to debride and clean the tongue because so much plaque is still on the tongue. Lets reduce that right at the beginning of the appointment. All this will help to reduce the bioburden in the aerosol coming out of the mouth.

#3. Yes, there is still aerosol that is created during these procedures so we use a tool right out of the SAFE Mercury removal protocols– we have a Hepa air filtration system, we warmly call “Snuffy”.

Snuffy has a long nose that will sit right under your chin as we work and all those air particles we don’t suction up with our high volume evacuation system will be immediately captured by this hose and disinfected.

Snuffy is an ACS- a commercially available air cleaning system. He has a HEPA pre-filter (HEPA stands for High Efficiency Particulate Air) which retains particles less than .3micrometers in size. A second filtration system includes four gas filter cartridges, and then a final filtration stage that is comprised of an electrostatically charged post filter. Here’s the research that confirms it’s success at reducing bioaerosol reduction.

Dr Taylor has two such systems. One is now in the hygiene department and will be used on every appointment. Dental hygiene tools generate a lot of aerosol but by disinfecting first – the teeth, the nose, the tonsils and the tongue we have effectively reduced the pathogen load throughout the mouth. Then, using ozone water in our “three way air/water syringe” as well as using ozone water during all procedures we can continue to keep the dental office air and you healthy. In addition to using ozone water, Dr Taylor and I also use ozone gas underneath the gumline to disinfect the tooth root surfaces and gum tissues below the gumline.

#4. In addition to Snuffy and Hepa filter system we will also have a negative air ionizer in each room to help sanitize the dental operatory air even further.

#5. Just a reminder, the corona virus can enter the body through ANY mucus membrane so really important to wear eye protection. We always give you safety glasses to wear so be sure to keep them on your face until the end to the appointment. They will of course be disinfected and clean and ready for you.

(When out and about keep your glasses or sunglasses on and keep your hands off your face. I was watching a zoom meeting and could see folks touching their faces repeatedly. I recently read we touch our face about 23 times an hour. After that meeting, I believe that statistic.)

#6. You may see us in more protective wear- called PPE – Personal Protective equipment. Face shields, disposable garments on top of our already waterproof OSHA and WISHA standard but stylish ClinicWear jackets. As the American Dental Association and the states finalize our future uniform standards of care we will be making changes. Sometimes it is a process. Be assured we follow all WISHA standards.

#7. Testing and Treatment – in addition to testing for the bacterial and viral pathogens, as well as tooth decay bugs, and nitric oxide, Dr Taylor is also offering a Vitamin D test into our wonderful office. Research is showing a direct connection between vitamin D shortage and our immune system’s ability to respond to the virus. According to the newly released research we should consider upping our vitamin D 3 (and Vitamin K2 because they go together) to 10,000 units for at least two weeks then drop down to 5000 units. It would be good to test to see where your starting levels are so we will offer that test in the office. This is such a great service to our patients because D3/K2 are vital for so many bodily functions and are critical to help heal gum disease.

Your oral health and wellness rests on your commitment to working with us to eliminate dental infections, oral diseases, breathing properly through a healthy airway, and then staying healthy. We will do all that we can to facilitate this transition. We are committed to educating ourselves and then sharing that information with you. Dental disease elimination is a cornerstone of true health.

#8. You will see much more screening paperwork, temperature taking, disinfecting, handwashing and pre- appointment toothbrushing for all patients.

#9. We, the dental staff will be doing extra disinfecting. We will not be scheduling patients back to back to allow more time to clean and disinfect, and allow the room and air to be cleaned. These disinfecting protocols take upwards of ten minutes.

#10. At night we will be ozonating the office air for a period of time to truly disinfect the entire office. Ozone for the win! This procedure is done to clean and disinfect every nook and cranny but must be done when no one is in the office.

Dental Treatment in the Time of Covid-19

Our goal is to keep us all safe so we can continue to see our fabulous patients, and be safe at home with our families. Please be patient with us as we learn along with you what works, what does not, and how much time this will take. Your safety is our utmost concern. Protocols should not be rushed.

Know we miss seeing you. I am sure I can speak for every hygienist when I say we miss our patients and look forward to going back to work. It is a scary and uncertain time but with the correct tools and knowledge we can improve dental and dental hygiene care. We will come out of this a better, more preventive profession than ever before.

Sincerely,

Barbara Tritz

Queen of Dental Hygiene, Nasal Breather, Vitamin D3/K2 lover and Corona Virus Killer

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