Renee Knight is a freelance writer and editor who's been covering the dental industry for 15 years. 

Renee Knight

During the past year, the coronavirus disease 2019 (COVID-19) pandemic has forced dentists to reevaluate their approach to safety. Dental teams have had to change how they schedule, extend appointment times to allow for more vigorous cleaning and update personal protective equipment (PPE) protocols, all while performing other infection control (IC) tasks.

Trying to get it all done can pose challenges to other critical areas such as productivity and patient experience. Efficiency is crucial. Adding protocols and tasks designed to enhance safety is not enough. Practices must consider how best to perform procedures. It starts with determining the minimal time needed for tasks that must be completed daily to keep everyone safe, says Gary Morgan, vice president and a senior compliance advisor for SafeLink Consulting.

“It’s kind of a time study,” he says. “You need to figure out how much time it actually takes to do this so you know how many patients you can move through efficiently, without causing yourself to have to stay longer at the end of the day or dealing with disgruntled patients who had to wait longer because you haven’t planned everything out efficiently. I see that struggle every day.”

To be successful, you must find that balance. It might seem daunting, but with the right training, guidance, and a clear plan, it certainly is possible.

Once you and your team members understand the reasons behind new protocols, implementing them will be easier, says consultant Marie Fluent, DDS, who is a member of the Organization for Safety, Asepsis, and Prevention (OSAP) and an IC expert. Such understanding comes from education and training. That means providing safety training as part of the onboarding process and evaluating staff performances throughout the year, says consultant, trainer, and speaker Karen Daw. Training should go beyond checking off boxes on a list; rather, proficiency must exceed minimum requirements or whatever guidance a product manufacturer offers. Team members should be able to complete the same tasks the right way every time, which might require comprehensive continuing education courses or bringing in a consultant.

Of course, this does not just apply to COVID-19 safety protocols. Now is the time to question everything that has been done and to think about what can be improved, says compliance/risk management specialist Linda Harvey. Team members need to find better, more efficient ways of completing tasks and to effectively incorporate new protocols and procedures into their workflow. “If you go back and look at HIV/AIDS, that really shifted our approach to safety in the dental setting,” Daw says. “Here is another opportunity for us to reevaluate whether the systems we have in place are working for us.”

A key to improving efficiencies is normalizing steps put into place to enhance safety, Daw says. You must adjust without compromising the quality of care or productivity, making it routine.

“Adapt these practices so they become habits and don’t take extra time,” says Luci Perri, owner and president of Infection Control Results. “It’s the same as getting up in the morning and brushing your teeth. It takes time but you don’t think about it because it’s just part of your normal routine.”

If you are uncertain about where to begin, you might consider partnering with a consultant, Daw says. Doing so can offer a fresh perspective on what is working and what is not and help you form a plan to improve efficiencies and grow your bottom line.

Whether working with a consultant or just with the team, developing standardized procedures will lead to better patient care, Harvey says. These procedures will ensure tasks are completed the same way every time, which reduces the possibility of error.

As policies are changed or added, write everything down, Dr Fluent says. Make it easy for team members to find protocols so that there is no confusion. You might consider appointing an IC coordinator to ensure policies are followed, Dr Fluent adds. This person should stay up to date on the latest regulations and policies from various organizations, which are constantly evolving, and train, educate, and encourage the rest of the staff as recommendations change.

Of course, whomever you assign to this position—whether it is a dental assistant, office manager, or hygienist—still has a primary job and could use help with these new responsibilities, says Chantel Willis, associate director, SBU, instrument management and infection prevention for HuFriedyGroup. That is where a solution like the GreenLight Dental Compliance Center by Hu-Friedy comes in.

GreenLight is an online portal that houses everything a practice needs for an efficient IC program, Willis says, and creates policies for optimal safety, saving time. With GreenLight, team members can find resources from the Centers for Disease Control and Prevention (CDC), the Environmental Protection Agency (EPA), the Occupational Safety and Health Administration (OSHA), and other organizations, along with any policies and protocols the practice has developed. The portal can be accessed for questions, training videos, patient communication forms, and other resources designed to ensure team members are in compliance and running their IC program as efficiently as possible.

The compliance hub also helps with onboarding, giving new employees a place for information they need about your practice’s IC protocols, Willis says. Whether bringing someone in for a few days or full-time, having standardized procedures ready and accessible is a huge time-saver. You can also send new employees training materials they can review before their first day.

“You have to have standards. You have to have a benchmark for how the practice will operate and expectations for your staff,” says Jessica Wilson, business development manager for IMS at HuFriedyGroup. “Every practice should look at their mission statement, vision statement, and brand and ask, ‘Who do we want to be? How do we want to show up, and where does compliance fit as far as safety for my staff and the patient experience?’”

Dr Fluent also encourages dentists to join OSAP. It’s the only IC organization dedicated to dentistry, she says, and is a great resource. Right now, all the information on OSAP’s website and its COVID-19 toolkit are available for free. This includes access to guidelines from the CDC, OSHA, the World Health Organization, EPA, and state dental organizations.

Instrument sterilization remains an area that could use an efficiency boost in many practices. Sterilizing can take time. It is critical to streamline the process for the sake of productivity goals and patient experience.

Morgan suggests having 1 employee dedicated to sterilizing instruments each day. If you have too many individuals in an area, they can obstruct one another and add confusion to the process. Putting 1 worker in charge of sterilization activities eliminates this problem and helps ensure no one has to wait for a clean instrument before being able to begin a procedure. For smaller practices, Morgan recommends determining the best time for sterilizing instruments to enhance everyday efficiency.

Some disinfectant sprays need to set for as long as 10 minutes before being effective, although others only require 1 minute, consultant Gary Morgan says. Finding sprays that are effective against COVID-19 in less time can do wonders for efficiency.

The standards you have for productivity should apply to safety as well, consultant and speaker Karen Daw says. That mentality will make you more efficient when it comes to safety tasks.



Through this service, HuFriedyGroup customers can submit photos and talk to a team member about challenges with sterilization, Jessica Wilson, business development manager for IMS, says. Customers then receive an analysis that points out opportunities for improved efficiency and compliance.

Single-use products eliminate the need for cleaning, adding efficiencies to a practice. Disposable high-volume evacuation valves are an example, Luci Perri of Infection Control Results says. Team members do not have to worry about sterilizing them between patients, saving time.



It is also a good idea to consider the size of your sterilizer, Perri says. If you use a tabletop steamer, evaluate how much it can hold versus how many instruments you need to sterilize each day. You might find it does not have enough capacity for how busy you are and that it is time to invest in a bigger system. Doing so saves time so that team members can focus on patients.

Using instrument management cassettes like the IMS from HuFriedyGroup eliminates steps in the sterilizing process, Willis says, making it more efficient and safer. With the IMS, team members do not need to handle contaminated instruments; they are rinsed, washed, dried, packaged, and stored in the cassettes. There is no sorting through instruments in cluttered drawers to find what is needed. Everything is color-coded and easy to identify. All of this saves between 5 and 10 minutes per procedure. The protected instruments last longer, which also reduces costs. “Reprocessing instruments is critical for the practice, but it’s not a revenue-generating procedure,” Willis says. “So the more time it takes, the more time it takes away from you doing other things.”

Reprocessing instruments in cassettes reduces the likelihood of sharps injuries, Willis says, enhancing safety and reducing the spread of blood-borne pathogens. Team members are not handling the contaminated instruments directly or sorting through instruments in drawers. Everything is properly spaced, packaged, and ready when needed chairside. “The less time spent around sharps and contaminated items,” Daw says, “the lower the risk and liability and overall cost to the practice in the long run.”

Although the goal is to avoid sharps injuries as much as possible, chances are they will happen from time to time—making it critical to have a protocol in place, Morgan says. Have all forms ready and accessible. The quicker you react, the quicker an employee can be treated. Morgan also suggests making sure everyone knows first aid protocols in case of an incident. This is something many offices may overlook.

“Every dental practice or clinic should have a blood-borne pathogens plan,” Perri says. “If someone gets stuck with a sharp or gets a splash of blood or body fluid on their skin or in their eyes, you’ll know exactly what to do. You also need to have a plan for who will determine whether the exposure requires medication.”

To ensure everything is running properly, it is important to implement quality measures in sterilization and IC areas, Harvey says. Those measures range from properly maintaining your dental unit waterline to loading cassettes correctly to conducting biological monitoring in your sterilizer.

Although 1 person should be responsible for each task, it is critical for everyone on the team to be trained, Harvey says, so tasks are never left undone if someone is out of the office. Just a few months ago, Harvey received a frantic call from a client who realized no one had been running the biological monitoring tip in the autoclave; they had been running only the chemical indicator tip. “When those errors happen, it puts the practice in noncompliance with CDC guidelines,” she says, “and many times not compliant with state laws.”

In a busy practice, it is easy to forget steps or to try seemingly harmless shortcuts to save time. Although you want to be efficient and productive, you must perform all the necessary steps in every procedure. Otherwise, you put patients and team members at risk and waste time dealing with problems that skipping steps can cause.

Not understanding manufacturer instructions for the various products used for IC also can cut into efficiency, Harvey says. It is important for team members to understand how a product works, why they are using it, and how it is supposed to be used.

“It can happen with something as simple as disinfectant wipes,” says Daw. “When team members read the label, they might discover they have a 2-step product that requires cleaning the surface, wiping it down, and then letting it sit for 5 minutes. You need to make sure you’re using it properly. If you don’t have minutes to wait, find a product with a shorter contact time.”

Investing in low-maintenance products also will help boost efficiencies so you stay more focused on patients and productivity, Daw says. Find high-quality products that eliminate steps in a procedure or reduce the amount of monitoring needed.

Before COVID-19, many practices had protocols and policies for wiping down common areas of the office that may or may not have been followed closely, Dr Fluent says. Now it is mandated, which requires more time.

Writing down policies that indicate which surfaces need cleaning and how often enhances compliance and improves efficiency, she says. Removing items like magazines and toys from reception areas also helps limit what needs to be wiped down, speeding this crucial task. Alleviating clutter and adding barrier protection in the operatories limits the time needed to clean between appointments, improving patient flow. Whichever disinfectant you use should be on the EPA’s List N to confirm it is effective against COVID-19, Dr Fluent says.

Practices not only need protocols for donning and doffing PPE, but also for storing it, Morgan says. It is critical that team members know how to handle gowns and shields after removing them so there is no cross-contamination.

Many team members hang gowns in different places or place them on something, Morgan says, making them hard to find, which wastes time and exposes them to cross-contamination. Dentists need to designate a home for all PPE so it is easily accessible and can be reused.

“I’ve seen someone hang up one gown and then someone hangs another gown on top of it. Now you have an exposed area touching the inside of an area that somebody is going to put on,” Morgan says. “I see that with face shields too. They hang 2 face shields together, contaminated side to not-contaminated side. It’s a challenge but you have to be cognizant of when you’re doing that.”

Of course, PPE must be removed more often, and hands washed more frequently, so ensuring everything the dentist and assistant need is in place before starting a procedure is crucial for improving efficiencies, Wilson says. If any instruments are missing, someone must get up, take off their PPE, get what they need, and put all the protective gear back on—wasting time and money. An IMS that makes instruments easy to identify helps with this.

COVID-19 has made scheduling more of a challenge and less efficient. For social distancing reasons, many dentists are asking patients to wait in their cars before appointments. That means practices must be more structured in how they accommodate patients, Morgan says, keeping them safely moving.

“The hardest part is controlling that flow. So, first thing in the morning, practices have 3 or 4 patients coming in and have to handle that by either going vehicle to vehicle and checking them in or having them come in 1 at a time,” Morgan says. “If you don’t plan that properly, it will start to add to your time during the day. If your practice opens at 8 and you don’t open your door until 8, you’re already behind the game.”

Dental teams also must now make time for pre-screenings, Morgan says. Instead of sending automatic reminders, many are now contacting patients directly to ask whether they have been exposed to COVID-19, which takes more time. One way to make this more efficient is to leave a recorded message or send a text asking patients to call back if they have had any symptoms and need to reschedule an appointment.

Improve Efficiencies and Grow Your Bottom Line

Safety has always been a focus in dental practices, but COVID-19 has really brought it to the forefront. In addition to what they have always done, dentists are now implementing protocols and procedures to keep everyone safe and at ease while they are in the practice. But doing so efficiently is the key to staying productive and providing patients with the best care possible. It comes down to finding that balance. The practices that can do this will have the most success.

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Find the right balance between protecting health and remaining profitable 

Safety, Efficiency Are Your Top Priorities

Irene Iancu first had the idea of opening her own dental practice in Canada about 10 years ago. Her vision was simple back then; it would just be her treating patients, with an office manager to keep everything running smoothly.

That evolved into the fully-functioning dental practice she opened in Toronto last summer. Toothlife Studio is a multidisciplinary dental studio where, as a licensed independent dental hygienist, Iancu is able to handle just about everything a general practitioner can, except permanent restorations and preparations.

The fact that Iancu is a dental hygienist and not a dentist threw people off, making it more difficult for her to get approved for loans and to purchase necessities such as anesthesia and x-ray equipment.

Still, being able to open her own practice is a testament to how far restorative hygiene has come in Canada over the years. While regulations and training requirements differ between Canada and the United States, and even province to province and state to state, direct access in the U.S. also has made great strides.

Currently, 42 states allow direct access, which means dental hygienists can practice without authorization from a dentist or without a dentist being present, according to the American Dental Hygienists’ Association (ADHA). That’s up from 28 states in 2008 and some states, such as Colorado, also permit hygienists to own their own practices.

In some states, however, hygienists can’t do much without dentist supervision. What is permitted depends on the state’s dental practice act. This is frustrating for hygienists who want to practice to their full scope because of the benefits this can provide, from increased practice productivity to improved access to care for underserved populations.

“The ability of a dental hygienist to initiate treatment based on their assessment of a patient’s needs without the specific authorization of a dentist, treat the patient without the presence of a dentist, and maintain a provider-patient relationship.”

Source: The American Dental Hygienists’ Association (ADHA)

Direct access has changed considerably over the years and continues to be redefined in state practice acts, says Katrina Sanders, RDH, BSDH, Med, RF, a dental hygienist and educator. Over the years, advanced instrumentation protocols have evolved and, in certain states, dental hygienists have been given the green light to perform other tasks on their own, such as administering local anesthetic.

“Expanded functions for the dental hygienist give us more autonomy and independence,” Sanders says, “allowing hygienists the opportunity to be more involved in the clinical aspects of patient care.”

Today, dental hygienists work in various settings and under different levels of supervision, according to the ADHA, with each state having its own laws in place to determine what services they can perform, where they can perform those services and the level of supervision needed. Most dental hygienists only provide supportive restorative services, limited to placing and finishing restorative material, with the dentist required to be present in most states.

Dental hygienists may opt to receive a restorative certificate by completing continuing education approved by the state board. Appling cavity liner/base, placing, carving and finishing amalgam restorations, placing and finishing composite restorations, placing and removing temporary restorations and fabricating temporary crowns are among the restorative services hygienists can provide, depending on state practice acts. With the proper training, some states allow dental hygienists to deliver restorations, Sanders says. Dental hygienists have the education in anatomy and diagnostics for this service, so it makes sense for them and the patients they serve. 

“Hygienists are known for being patient advocates and educators,” Sanders says. “Who better to sit and guide the patient through the entire experience of receiving a dental restoration? Who better to explain [the process] than someone trained as a patient advocate? Hygienists can step into their power as educators to make the dental experience more comfortable for the patient as well.”

Depending on state practice acts and training, hygienists also might be able to complete simple extractions; work in nontraditional areas such as mobile dental units, schools, community health care clinics, Native American reservations, and senior living facilities; and own practices.

Although things have been slow going, they are improving. When legislators first began making changes to state dental practice acts, the process was somewhat drawn out. Dental hygienists might first be allowed to provide services in schools, and then nursing homes and community centers would be added later. Now states such as Indiana, which became a direct access state in 2018, are skipping the phased approach and allowing dental hygienists to provide services to the top of their scope.

In recent years, more states, like Minnesota, have begun to introduce the concept of a dental therapist. About half the dental therapists in Minnesota, which became the first state to authorize dental therapy in 2009, are dually licensed as dental hygienists. That continued interest in dental therapy represents an evolution in expanded hygiene, with these dual-licensed providers able to offer both preventive and restorative care.

Number of states that allow direct access

Direct access can fill a critical gap for underserved populations. Communities with a shortage of primary, dental, or mental health care providers are known as Health Professional Shortage Areas (HPSAs), according to the 

. HPSAs can represent a shortage of providers for an entire group of people within a defined area (geographic HPSA) or a shortage of providers for a group of people within a defined area (population HPSA). Residents in these communities struggle to find high-quality dental care.

In some states, depending on the scope of practice, dental hygienists can provide that care, which is why direct access is having the biggest impact in community oral health clinics, Sanders says. These clinics can employ 1 doctor as well as several direct access dental hygienists. While the doctor is diagnosing and prepping teeth, hygienists can handle the restorative piece. As a result, more patients are seen at a lower provider cost. Practices that treat mainly Medicare and Medicaid patients are also starting to use this model, but of course only if allowed by the state’s scope of practice.

Beyond providing care to underserved populations, dental hygienists also can spend time educating patients and putting an emphasis on prevention, as dental hygienists are the prevention experts.

“Preventive dentistry is ingrained in us,” Iancu says. “We try to save teeth as best we can. Dentists are taught to treat more than to prevent. That’s where our skills could be more focused and used to help these communities in need.”

Probably the biggest barrier to direct access lies in states’ dental practice acts, Sanders says. Every state is different, and some have been slow to make the changes necessary to allow hygienists to perform to the top of their scope of practice using the full extent of their education.

Then there is the dental community itself. Many dentists are hesitant, concerned that hygienists don’t possess the skills necessary to perform restorative work at the same level as they do, Sanders explains. Some also may feel threatened, if basic dental work can be handled by a provider with a lower salary.

“It’s an interruption of the normal workflow in dental practices,” Sanders says. “It takes training for the doctor and hygienist to work in tandem and to have a structured schedule, yet it makes sense from a clinical and financial standpoint for these practices.”

Some dentists struggle with relinquishing control and putting faith in another person, Iancu says, which keeps them from giving hygienists more autonomy, even in provinces or in the U.S. states where it’s allowed. But there are dentists who support direct access and see these providers as a resource and an ally, not as competition.

Education is another obstacle. Some hygiene programs include restorative training, but right now many don’t. And although there are programs available to hygienists who want to expand their skills, they often cost thousands of dollars, Sanders notes. If there is no financial support from the dentist, many hygienists simply can’t afford it.

The level of education required for certain functions depends on what state, or in Iancu’s case, province, you live in. Iancu is working to get her restorative dental hygiene license, which will give her the ability to perform fillings, temporaries, and permanent restorations in her Toronto practice. Her 6-month program is fairly intense and difficult to get into, but when she has finished, she’ll have a new skill set and a new focus. So, it’s not only about managing the expense but about balancing your time and committing to practicing in a new way.

Incorporating direct access hygienists into a practice does require a new way of working and will look different in every state.

First, both dentists and dental hygienists must determine what their state allows, Sanders says, then evaluate which steps in a procedure dental hygienists can take on. Once the diagnosis is made, what are they able to do? Can they deliver anesthesia or place a restoration?

“What you’re doing is evaluating the best opportunities within the patient appointment flow chart,” Sanders says. “What are the best opportunities to bring a hygienist in to perform certain functions? When the dentist and hygienist are working in tandem, it’s almost like ships passing in the night, with the hygienist performing the vast majority of the direct patient care.”

Of course, there are dentists who are already embracing this model in their practices. Some clinicians bring direct access hygienists on rather than hiring associate dentists and giving part of their patient base away, Iancu says. Instead, they opt to work in tandem with their hygienist, giving them the ability to see more patients each day.

“The idea is not for the hygienist to be stepping into the role of a dentist,” Sanders says. “We very much respect our doctors for the skills and talents they bring to the practice. But onboarding highly trained clinicians who can [provide] support in the restorative piece and provide high-level care gives doctors the opportunity to expand the quality of care in their practice, and to do so while optimizing their overhead.”

A lot of progress has been made over the years, but more work needs to be done. As a growing number of community oral health programs turn to direct access dental hygienists to help fill gaps in patient care, programs in other states will take note and begin to do the same. That’s when people will really start to see change, Sanders says.

“One state will look at what’s successful in another and learn from that, and then slowly other states will begin to adopt the pieces that worked as well,” Sanders says. “It really starts with the community oral health programs. This is where we’ll see eyes opening across the industry.”

Additionally, practices serving patients with a lower socioeconomic status will turn to the community health care model, Sanders says. They will employ more direct access dental hygienists to optimize patient care while keeping overhead low. Eventually, these providers will become a normal part of any dental practice, and there will also be an increase in the number of dental hygienists who opt to open offices of their own.

Standardizing guidelines would also help, Iancu says, making it easier for hygienists to practice to their full scope while also allowing them to move freely. Currently, if Iancu goes to another province, her license may not transfer. The same situation exists in the United States. In one state, hygienists can own their own practice and work without dental supervision, whereas in others, they can’t practice independently at all.

So, although progress has been slow, it has been steady, and continues to gain momentum.

“If dentists are onboarding highly trained clinicians who can support the restorative piece and provide high-level care, that provides an opportunity to expand the quality of care in the practice, and to do so while optimizing overhead,” Sanders says. “It’s important for dentists to learn what these providers can do to help support their practices.”

Direct access dental hygienists are gaining momentum, but they still face challenges.

Direct Access Dental Hygiene: How Far It’s Come and Where It’s Going

Reducing aerosols in dental operatories has become a top priority since the coronavirus disease 2019 (COVID-19) pandemic hit earlier this year. Aerosol transmission is among the ways COVID-19 is spread, and when compared with droplets, they are much smaller, travel farther, and stay in the air longer. That’s why it’s critical to reduce aerosol production during dental treatments and for dentists to invest in products that minimize the possibility of cross-contamination and air contamination—and that includes handpieces.

These handpieces come with NSK’s infection prevention features and meet the same performance standards of other attachments but are 10% smaller and lighter than conventional models.

Used in conjunction with the NLZ micromotor system, the nano series offers the maneuverability of an air turbine for more accurate treatments. The balanced handpiece reduces fatigue and improves fingertip dexterity. The titanium body with ceramic bearings and diamond-like-carbon (DLC) applied to the gears offers optimal durability.

According to Alfred Hayrapetian, product manager at NSK, handpieces come with a variety of features designed to keep the air clean and have been that way since the early 1990s. NSK’s proprietary Clean Head System and the anti-retraction valve are designed to reduce the infection risks aerosols create for both dental teams and patients.

Infection prevention has been a priority at NSK for 30 years, with the handpiece manufacturer offering comprehensive solutions designed to prevent air contamination and put the safety of dental teams and their patients first. And products with a history of reducing aerosols and cross-contamination bring comfort to patients who are nervous about visiting the dentist, especially during a pandemic.

“A clean and disinfected environment including equipment and instruments used directly in contact with a patient is essential in a dental office,” says Hayrapetian. “Handpieces are used directly inside patients’ mouths and are at the forefront of this type of equipment. Cross-contamination is on top of the list of concerns for a patient who sits in a dental chair.”

The Clean Head System and the anti-retraction valve combine to create what the company calls the Dual Defense™ system to control infection, with one preventing suck back into the handpiece head and exhaust line and the other protecting against waterline contamination.

According to Hayrapetian, when using spray water, dental handpieces can produce a significant amount of harmless aerosols unless the equipment is contaminated. NSK’s Clean Head System is designed to prevent contamination. A small, built-in structure is located near the bur and creates a pressure difference between the outside and the inside of the handpiece. Why is that important? It keeps foreign particles and contamination from getting into the handpiece.

“This system will keep the handpiece in a clean state,” says Hayrapetian. “And reduce the chance of cross-contamination between patients.” All NSK handpieces feature the Clean Head System.

The second part of the Dual Defense System, the anti-retraction valve, is designed to protect against cross-contamination in the waterline. How does it work? Once the foot pedal is released, the valve immediately shuts to stop airflow.

“This prevents a backflow of water and foreign particles from entering the internal water system,” says Hayrapetian.

All NSK handpieces, such as couplers and micromotors, come with anti-retraction valves. “With all NSK handpieces being equipped with Dual Defense as a sustainable system that can help prevent aerosol viral transmission, doctors can provide peace of mind for their patients who undergo a dental procedure,” says Hayrapetian.

And this system is proven. The Dual Defense System has been tested and validated by well-known universities, including the University of Washington, Umeå University in Sweden, and National University of Singapore.

How a handpiece is designed is also key to infection control. Recently, the team at NSK made some comparisons to show dentists their best options for handpieces. Through the NSK Aerosol Experiment Project, the company tested different handpieces to determine which types produced the most aerosols and which produced the least. The team tested electric handpieces versus air-driven handpieces, electric handpieces with and without chip air, and all with or without a suction system.

Electric highspeeds performed the best, producing significantly fewer aerosols than air-driven highspeeds, reducing the risk of contamination and infection to dental teams and their patients.

“As NSK has made its mission to help clinicians to go back to work and patients to be treated in a safe environment during this pandemic, it’s imperative to have reliable studies to prove the efficiency of our handpieces to work without chip air and produce fewer aerosols,” explains Hayrapetian. “NSK has made big investments in equipment for video recording in green laser light to track the droplets and aerosols with high standards.”

Investing in the right handpieces is key, but they also require proper maintenance. It’s critical to clean and lubricate handpieces as soon as possible after every treatment. Properly maintaining handpieces not only prevents cross-infection but also gives the instruments a longer life and reduces the risk of them overheating while in use, which can cause burns.

“To prevent cross-contamination between patients, proper sterilization is mandatory,” says Hayrapetian. “Handpieces need to be maintained and protected under the extreme heat and humidity applied by autoclave machines. Just like any other mechanical equipment, proper maintenance guarantees the longevity of dental handpieces. There are certain protocols for cleaning, lubrication, and sterilization of dental handpieces recommended by manufacturers that users need to follow.”

All NSK products come with reprocessing instructions that detail essential maintenance steps, ensuring dental teams properly clean their handpieces so they are safe to use. The company also offers the iCare machine for automated cleaning and maintenance of handpieces.

While infection control has always been a priority in dental practices, the COVID-19 pandemic has brought it to the forefront in recent months. Dental professionals are investing in new products and implementing new workflows designed to protect team members, patients, and themselves from contracting the virus. They’re looking into new ways to reduce aerosols, from fogging their operatories to investing in air filtration systems.

Properly reprocessing handpieces is also a critical part of dental practice infection control. NSK offers solutions to clean and lubricate handpieces. Using these solutions to properly maintain handpieces not only provides optimal infection control, but it also will extend the life of the handpiece.

The iCare is one of these solutions and handles the cleaning and lubrication of handpieces.

As dentists think about what they can add and what new precautions they can take, it’s also important to remember there are tried-and-true products shown to reduce aerosols during dental procedures. NSK has made infection prevention a priority for years, offering handpieces with infection control measures built into their design.

“Aerosol contamination is one of the highest risks in a dental clinic environment and has raised concerns, especially during this time of global pandemic,” says Hayrapetian. “NSK has developed systems that can minimize the possibility of cross-contamination and air contamination with our products promoting a safer environment for both doctors and patients since the early 1990s, long before this current pandemic.

NSK handpieces incorporate features that promote infection control—and have for the past 30 years—helping to keep dental professionals and their patients safe.

Designed for Safety

The Jade air purifier is a medical-grade air system that features a negative ion generator and 6-stage filtration and sterilization that captures dust particles, bio-aerosols, viruses, allergens, odors, and more. The unit is said to be remarkably quiet as it delivers 6 changes per hour. At just 33 inches tall, the JADE system is compact and is compatible with a standard outlet.

John Megas Jr, DMD, a periodontist with 2 practices in Massachusetts, first invested in the Cascade and JADE air purification systems from Surgically Clean Air about 2 years ago, equipping both offices with multiple units. As a member of the International Academy of Oral Medicine and Toxicology, he was interested in dental operatory air quality and wanted to find systems that effectively remove harmful molds, viruses, and bacteria.

After the coronavirus disease 2019 (COVID-19) shutdowns, Megas decided to invest in additional units. He felt he needed even more air purification to keep everyone safe, he says, and communicated his commitment to air quality to his patients through e-newsletters and chairside talks.

“Before we reopened, we let patients know we were following CDC [Centers for Disease Control and Prevention] recommendations, but in addition to that, we also have Surgically Clean Air systems, and we consider that a step above normal air filtration,” he says. “Patients were very responsive to that. The first thing patients comment on when they walk into the practice is how fresh and clean the air smells and how it feels energized. I’ve been thrilled by that.”

The Cascade, the larger of the systems, uses the company’s 6-stage filtration process to capture dust particles, pollen, volatile organic chemicals, mold, allergens, viruses, odors such as formaldehyde and smoke, bio-aerosols, nitrous oxide, and other pollutants. It can quietly clean the air throughout indoor spaces up to 1,700 square feet and features a sleek design.

The more compact JADE unit is designed for smaller spaces and features the same filtration technology, modern design, and quiet operation, turning over operatory air every 5 minutes. Both units produce negative ions that bind to positive ions in the air to improve and energize it.

“I even have a few of these units in my home. I’m addicted,” Megas says. “I’m in the process of buying another office, and when I walked in, I said, ‘The air quality is terrible.’ So, I’m going to have to do something about that.”


Maintenance is simple, according to Megas. When a filter needs to be changed, he gets an alert. One of his assistants removes the filter and puts it in the shower for cleaning. He puts a backup filter in so the system can continue running.

The UV-C light system, which has been shown to kill bacteria, viruses, and mold, is also easy to maintain, Megas says. It must be changed every year, but again, the system indicates when the light is becoming weak and needs to be switched out.

Although Megas can’t say for certain whether anyone in his practice has gotten sick since he invested in the Surgically Clean Air systems, illnesses in team members are now short-lived and no longer spread through the office. His team members love the fresh air that greets them when they enter the building, and one employee who has allergies noticed an improvement and looks forward to her time in the office.

Patients appreciate the practices’ commitment to keeping the air clean, especially with concerns surrounding COVID-19. “The dental environment is pretty toxic, and that deserves attention,” Megas says. “If you’re serious about taking care of your patients, your staff, and yourself, you really need to clean the air. Standard HVAC (heating, ventilation, and air conditioning) systems recirculate and clean the air somewhat, but, at this point, I don’t think that’s enough for a dental office. Patients are very receptive to coming back into the office knowing we have this air-sterilization system operating. It’s reassuring for everyone.”

One dentist uses this system to clean the air both at work and at home.

An air filtration system that removes viruses, bacteria, and heavy metals

At the beginning of the coronavirus disease 2019 (COVID-19) shutdowns in March, Kathy DeLucco, an expanded function dental assistant and Occupational Safety and Health Administration safety coordinator at Vermont Dental Care, watched a webinar on the QuickPass In-Office Dental Water Test from ProEdge. Impressed with what she saw, she signed up for a free sample.

QuickPass delivered everything promised in the webinar, and DeLucco was floored by the amount of time it saved. The office officially made the switch in early April.

What DeLucco liked most was how easy the test was to read. The system she had been using was not: Dark dots formed on a dark background to indicate the colony-forming unit (CFU) count but were often difficult to decipher, creating a time-consuming and frustrating task.

QuickPass is completely operator-friendly, she says, calling that statement indisputable. “QuickPass has the 3 C’s—it’s concise, convenient, and cost-effective,” she adds. “It’s very clear what the results are. If you see a little red dot on the white background, you have CFUs forming. If you don’t, then you’re good to go.”

The test has a short incubation period of 48 to 72 hours. Samples collected on a Friday evening before the team departs for the weekend are ready for reading when they return Monday.

To test operatory water, DeLucco collects a separately pooled sample in each operatory from all hoses connected to the water supply, places the paddle, shakes for 2 minutes, empties the water, and puts the paddle back into the receptacle, leaving it undisturbed for 48 to 72 hours—a quick, easy process.

Vermont Dental Care has 9 operatories plus a reverse osmosis source tank. DeLucco can collect the samples needed for testing within 20 minutes.

The QuickPass In-Office Dental Water Test offers a simple, microbiological analysis of procedural water for dental treatment. Each QuickPass provides an estimated heterotrophic plate count to measure compliance with the CDC standard for safe water of no more than 500 CFU/mL. Every test comes with a consultation with the ProEdge team. A water safety specialist will help with reading results and best practices.

Typically, the practice would shock and test the water in-office quarterly and send a sample to the lab for testing annually. Upon reopening from the COVID-19 shutdown, all lines were shocked and tested in-office. The ProEdge QuickPass was advantageous for confirming less than 500 CFUs prior to reopening. Two operatories and the source failed the initial tests. With the ProEdge QuickPass, the team effortlessly reshocked and retested the water. Once the water passed the in-office test, they sent samples to the lab for verification.

The team at ProEdge is well versed in water quality, DeLucco says. They are quick to respond when questions come up and available to offer support—another benefit of switching to QuickPass.

The uncomplicated product wowed DeLucco the first time she used it. She was impressed with the time efficiency QuickPass offered compared with the product she was using before she watched the webinar. Such time savings are a tremendous benefit for any dental practice, especially now.

“With COVID-19, donning/doffing our PPE [personal protective equipment] is acutely more time-consuming [compared with] prepandemic. The furthermost project in your daily routine, in my opinion, would be a complicated, time-consuming water quality test,” DeLucco says. “As we all strive for personal excellence in dental care for our patients, it’s crucial in the dental operatories to use only water with less than 500 CFUs. It would take 45 minutes to view all the samples once they had incubated [with the previous product]. I would have to really scrutinize and enlist the use of my dental loupes because of the black background. With QuickPass it is obvious: If there are red dots, you need to shock; if there are no red dots, fabulous—it’s negative; let’s send it to the lab for verification.”

The QuickPass water test saves 1 practice time and money.

The only in-office water test designed specifically for dentistry

Fears of spreading coronavirus disease 2019 kept dental practices across the country closed for months. As offices begin to reopen, everyone is exploring how best to protect team members and patients from this disease.

While infection control (IC) has always been a priority, the COVID-19 pandemic has brought it to center stage. Dentistry is one of the occupations at highest risk for spreading the virus, and clinicians must take extra precautions, according to Sharon Ward-Fore, an infection prevention consultant. COVID-19 is transmitted through aerosol droplets, which can be plentiful during many dental procedures, and social distancing isn’t an option when treating patients chairside.

There are many infection control technologies that help limit exposure to coronavirus, but it can be difficult to keep track of all the options. How do you know what will work best for your practice, and how will you communicate the changes to your team members and patients?

First, stay up to date on guidance from the Centers for Disease Control and Prevention (CDC), the American Dental Association, and other national and state authorities. Recommendations shift as more is learned about the virus, so make it a priority to stay informed and adjust IC protocols as needed.

Aerosol prevention and reduction, air filtration, surface disinfection, personal protective equipment (PPE), and instrument sterilization are all IC areas that need extra attention these days, requiring updated procedures and protocols that will likely be with dental practices for years to come.

“We’re not out of the woods at all,” Ward-Fore says. “It’s not like this is over and it’s back to normal. We’re in the maintenance phase, and this is where we can’t get complacent. We need to be at the top of our game.”

While many dental procedures produce aerosol droplets, there are steps that can be taken to prevent and reduce them. One of the best ways is to use a rubber dam, Ward-Fore says. This underused, old-school IC method can be quite effective in protecting you and your team members from COVID-19.

Ward-Fore suggests using disposable rubber dams rather than those with reusable frames. There are some available that cover part of the nose, fully protecting dental professionals from exposure to respiratory droplets and aerosols.

“This is a super simple technology that should be embraced by all,” Ward-Fore says. “It goes in the patient’s mouth and kind of seals it off so the practitioner is working only in a protected field. Just the teeth that need to be worked on are exposed.”

Isolation devices such as the Isolite from Zyris are also effective at aerosol reduction. Ward-Fore described the Isolite, which combines light, suction, and retraction, as a “rubber dam on steroids.” The Isolite features a fitted mouthpiece that protects soft tissue and the airway while also providing retraction. Its suction capabilities make it possible to continuously evacuate saliva and debris, while the LED provides proper visibility into the field. The Mr. Thirsty isolation and suction device from Zirc and the Isovac dental isolation adapter from Zyris are other products that make isolation easier.

A high volume evacuation (HVE) system also is critical, Ward-Fore says. HVE devices, such as the Purevac HVE system from Dentsply Sirona, essentially remove aerosols before they even leave a patient’s mouth.

HVE is common in procedures the doctor and assistant complete, but hygiene generally uses saliva ejectors, says Mary Govoni of Mary Govoni & Associates, a Kansas-based company that coaches dental practices on safety. Since the pandemic, she has started advising practices to use HVE for hygiene patients as well.

“The hygienist needs something that has more volume to it than a saliva ejector,” Govoni says. “If the hygienist is scaling or polishing and using an ultrasonic scaler, the saliva ejector will remove fluids but it’s not controlling the aerosols.”

There are extraoral suction devices that can be used to control aerosols, and there are also portable units, Govoni says. The Extra Oral Suction System from ADS, for example, features an arm that can be placed near a patient’s mouth to remove aerosols. A similar product, the A~flexX HVE Arm, attaches to the back of a dental chair and holds the HVE hose with a suction tip or funnel placed outside the patient’s mouth.

Another way to reduce aerosols is to put the ultrasonic scaler away and instead hand scale, at least for now.

“I recommend going back to more manual practices and using four-handed dentistry,” Ward-Fore says, “so there’s someone there who can manually help you and keep the level of aerosols down.”

Many dentists are investing in high-efficiency particulate air (HEPA) filtration units to minimize the risk of coronavirus exposure. Standalone units are available, or a professional can come in and install an in-duct system that creates the ideal number of air exchanges.

An air filtration system traps particulate, with its effectiveness measured by how many times it can cycle the air, says Buzz Thompson, IC expert and founder of GermFree MD. HEPA filters offer a greater degree of filtration for trapping particulate. The more air that goes through these devices, the more particulate the devices trap.

Newer technologies not only trap the particulate, but they “trap and zap,” Thompson says. Ultraviolet (UV-C) light is an example of a “zap” technology. With UV-C systems, air is drawn into the handling unit and the UV-C light is applied to the trapped pathogen to render it inert. The challenge is that UV-C light is very effective, but only if it has enough contact time.

UV-C light can be distributed in-duct or via standalone units. Rooms still need to be cleaned prior to disinfection when this type of technology is used, Ward-Fore says, and standalone units can run only when the room is not occupied. It should be noted that UV-C has not been proven effective against COVID-19.

A newer technology to consider is air scrubbing. ActivePure, an air and surface scrubbing technology created in cooperation with NASA, can zap the air quickly without having to trap, Thompson says. The device turns humidity into hydrogen peroxide molecules that are safely distributed to clean and disinfect the air and any surfaces contacted, such as door handles, countertops, and surgical equipment. Thompson recommends placing the units in reception areas and operatories. They can be used to purify the air 24/7.

“Now we have a mechanism for occupied space infection control that’s effortless and highly effective,” Thompson says, noting that different types of air filtration can be complementary. “The ideal solution is something that’s proven, cost effective and requires little to no behavior modification. Combining air scrubbing devices in addition to an in-duct HEPA system, possibly with UV-C light in the duct work, provides a really nice package for a practice.”

UV-C wands are another option, but using them can be time consuming and tedious because you have to slowly go over the areas you want to disinfect, Thompson says. There are also aerosol sprays, but most tend to be toxic and don’t provide 100% saturation. Many dentists are turning to foggers, which are stronger than aerosol sprays. These devices can be effective, but fogging after every patient takes time and isn’t realistic for most practices.

Another challenge with foggers is the room must be cleaned before use, Ward-Fore says. Cleaning must occur prior to disinfection to allow the disinfectant to touch the cleaned surface for the manufacturers’ stated contact or dwell time. And the hypochlorous acid mist that foggers release has an odor that may bother patients or team members with respiratory conditions.

Govoni urges caution because studies validating fogging’s effectiveness are still being completed. While the mist released is nontoxic, she’s concerned with the potential for the particles to cause problems with technologies in the treatment rooms, especially if the solution isn’t at the ideal concentration.

Treatment rooms should be disinfected after every patient using hospital-grade products with a kill claim for mycobacterium tuberculosis. That’s been the standard for years, Govoni says. Mycobacterium form spores and are difficult to kill, so if a product is effective against that, it will be effective against COVID-19. Any disinfectant you buy should have the mycobacterium tuberculosis kill claim; if it only protects against coronavirus, it may not be strong enough to take out other harmful pathogens. 

On the Environmental Protection Agency (EPA) website, (epa.gov), you can find List N, a list of disinfectants that can be used to kill the coronavirus. All products on the list meet EPA’s criteria for use against SARS-CoV-2, the virus that causes COVID-19.

When cleaning operatories, Govoni recommends using disinfecting wipes instead of sprays. Sprays can be taken up in the air conditioning/heating system and circulated, possibly causing respiratory issues for team members, even if they’re wearing proper PPE. AdvantaClear, CaviWipes, or similar products are great options, or you can make your own. To do so, saturate 4x4 gauze in disinfectant, but don’t leave the gauze to soak, as that can deactivate the ingredients.

Putting plastic barriers on equipment and changing them between patients can reduce the amount of disinfecting necessary and save time, Govoni says. Barriers are something that will likely be more common in operatories. The biggest change in treatment rooms may be the removal of unnecessary items, such as pictures or patient brochures, because they can become contaminated with aerosols or droplets and potentially spread the virus.

“Don’t have equipment sitting out on the counter for the next patient,” Ward-Fore says. “Make sure everything is tucked away in cabinets and drawers and don’t have any paperwork in the room. It’s a common-sense approach of limiting the amount of items that can be contaminated and making it easier to clean.”

PPE is key to keeping your team members and yourself safe. Not only do you need to wear more PPE now, you also must know how to properly put it on and take it off to avoid contamination.

For face masks, N95 respirators offer the best protection and should be worn during aerosol-generating procedures, Govoni says. While these were difficult to obtain early on in the pandemic, they should now be available. Try multiple vendors to secure these masks for your team.

If you can’t find N95s, then KN95s are the next best option, Govoni says. Both filter out at least 95% of airborne particles and must be fit tested. The N95 respirators allow you to breathe in and out of the device, and have 2 straps, 1 that goes on the top of the head and 1 behind the neck. KN95s and regular masks, which don’t offer the same protection, only have ear loops.

Whether you’re purchasing N95s or KN95s, work with a reputable vendor that isn’t trying to sell you counterfeits. The CDC and FDA offer resources to ensure sure you’re buying the real thing.

If neither the N95s nor the KN95s are available, a surgical mask can be used, Govoni says, but avoid performing aerosol-generating procedures on anyone suspected of having or diagnosed with COVID-19. These patients should be sent to a hospital that has the proper protections in place for treatment.

Per the CDC, dental professionals also should wear gloves, full face shields instead of goggles or safety glasses for eye protection and single-use, disposable gowns that are changed and disposed of after every patient. Gowns, which may be covered with droplets or splatter, should be taken off in the treatment room, Govoni says. The CDC also recommends wearing hair coverings because droplets or aerosols may settle in hair during procedures. Shoe coverings also are recommended.

While it has been recommended by some to put gloves on in front of patients so they know you’re taking the safety protocols seriously and not walking from op to op with the same PPE on, the CDC states in its interim guidance to put on clean, non-sterile gloves prior to entering the patient room.

“You also need to be diligent on how you wear your mask. It needs to cover your mouth and your nose,” Ward-Fore says. “You have to be all-in and wear everything appropriately. And if you touch your PPE and you’re wearing gloves, it’s time to strip those gloves off, do hand hygiene and put on a new pair of gloves.”

Ward-Fore recommends using disposable products as much as possible, but for reusable instruments, it’s important to follow the manufacturer’s guidance on how to properly clean and sterilize them. The foam or gel pre-cleaner is used to prevent blood or tissue from drying on the instruments, which makes them harder to clean. The pre-cleaner keeps the debris soft, making it easier to clean 

 to placing them in an autoclave or sterilizer for disinfection. Perform the necessary quality control on your sterilizer to ensure it’s working properly, and make sure instruments are clean and dry before they’re packaged, Govoni says. If packages are put away wet, they could tear, compromising sterility. Conduct spore tests weekly on sterilization equipment, and follow manufacturer instructions for proper maintenance and use.

An instrument management system (IMS), such as the one from HuFriedyGroup, can help ensure instruments stay organized and clean, says Jessica Wilson, business development manager for HuFriedyGroup. When ready to be sterilized, the instruments are placed into a cassette that keeps them separated during reprocessing, maximizing the number of instruments that can be put into equipment at once while also ensuring they don’t get tangled and damaged. Placing instruments into a cassette also ensures they’re loaded properly in the sterilizer to achieve proper sterilization between patients. The cassettes feature color-coded labels to make it easy to match instruments to procedures.

“With this system, they have everything they need to sit down and finish that procedure,” Wilson says. “If the instruments aren’t organized, they have dental team members getting up in the middle of the procedure when PPE preservation is at an all-time focus for practices. They need to be organized when they sit down to avoid having to leave the room for anything until the treatment is completed.”

Investing in such a system shows your team and patients you’re serious about keeping them safe, Wilson says. Team members are protected from sharps injuries, the practice improves efficiencies, and the patients receive visible safety measures by having cassettes unwrapped in front of patients.

It’s important to get team members involved in the changes you’re making and for them to understand why they’re vital to protecting everyone in the practice. Offer training, which might include how to properly don and doff PPE and consider putting a team member in charge of your IC efforts.

Think of this team member as the voice of safety, Wilson says, and the person who communicates with patients about new precautions the practice is taking. The IC coordinator can research the various IC technologies to help decide what would work best for the practice, and they should stay informed on the latest guidance.

Make it clear to team members that everyone needs to follow the same protocols, Govoni says, and explain the rationale behind them. The GreenLight Dental Compliance Center by HuFriedyGroup can help with that. The website’s

tools (greenlightcompliancecenter.com) enables dental practices to create written documentation and protocols for all areas included in the CDC infection control guidelines. Each protocol includes specific, customizable steps for practices to follow. The information reflects what is actually being done in the practice and fulfills a need for documentation that many practices overlook. This helps promote consistency with how IC tasks are performed. The comprehensive online tools also include auditing so practices can ensure they’re following proper protocols.

There’s no doubt coronavirus has changed dentistry. The products and procedures you’re implementing now will be part of your practice for the foreseeable future, making it critical to choose the IC technologies that will work best for your practice while keeping everyone safe from exposure to coronavirus.

“This is for the long haul,” Ward-Fore says. “It may be how dentistry and health care functions from now on. Maybe if we build these changes into our day-to-day practices now, we’ll be better prepared for the next big thing we didn’t know was coming. We’ll be more protected.”

With the COVID-19 pandemic’s spotlight on infection control, it’s vital to know what products offer the best protection. Here’s how to incorporate infection control technologies into your dental practice’s workflow.

Infection control technologies keep dental teams, patients safe

	Dr. Joe Willardsen is committed to providing patients with minimally invasive dentistry. When placing a restoration, he aims to save the tooth structure, so he focuses on increasing bond strength without relying on mechanical properties that require cutting down the tooth. High bond strengths require clean restorations, and that’s where Kuraray’s KATANA Cleaner comes in. 

“In the process of trying in a restoration to make sure it fits, it gets contaminated with blood, saliva, and plaque,” Willardsen says. “If the restoration isn’t cleaned out properly, my bond strength is almost cut in half.”

	A few months ago, he started using KATANA to clean restorations. Although relatively new, the product is backed by research that shows its ability to clean effectively, both intraorally and extraorally, something other cleaners can’t do. Combining a pH of 4.51 with the surface-active characteristic of MDP salt quickly and thoroughly cleans restorations, ensuring that patients leave Willardsen’s office with a restoration that lasts. 

	“KATANA Cleaner is a huge advantage for me,” he says. “It’s the only cleaner that not only disinfects the restoration but is also safe to use in the patient’s mouth. So, I decontaminate the restoration and the tooth itself. With other cleaners you’re not able to do that, usually because the pH of the product isn’t right.”


	Willardsen’s goal is to spare patients the downward progression from fillings to restorations to root canals to extractions. The best way to do that is to keep more of the tooth structure, which KATANA helps make possible. 

	“With this process, I don’t have to be as aggressive,” he says.” I don’t have to rely on mechanical retention, and I can keep more of the natural tooth, which, in the long run, prevents my restorations from having to be changed over and over again.” 

	Patients appreciate Willardsen’s determination to provide long-lasting restorations. He tells them about the cleaner and explains that it disinfects their tooth to ensure that no bacteria will be permanently cemented underneath. 

Closer Look: Clean up contamination and improve dental bond strength. This new cleaner helped one doctor boost bond strengths and offer minimally invasive dentistry. 