¶ Welcome to Season Three
Hello and welcome back to season three of Level of Infection Prevention podcast. I'm Michelle strange and I'm excited to have you join me as we dive deeper into the nuances of infection prevention and patient safety. Yeah. Yeah. Yeah.
¶ Understanding Backflow in Dental Practices
And today we're going to be talking about backflow and suctions and. Some things that we don't really, I don't think get enough, screen time, if you will. I think it's a topic though, that is so important in creating those safer dental visits. And so I'm thrilled to be joined by Amanda Hill, who brings a wealth of knowledge and I think also practical insights to the table. So welcome Amanda to the show.
Thank you for having me, Michelle, and I'm always happy to talk about the grossness of backflow.
Okay, so let's start with what is, what are we even talking about? Why does this matter?
So backflow is when previously suctioned fluids meaning the patient before, then end up in the next patient's mouth. And that occurs when our patients create more pressure on the suction than is coming from the vacuum. So that means when they have their makeout session with the suction to get out all the fluids from their mouth, or we as clinicians say, okay, close down nice and tight because we say it. We say it. when we do that, that then puts that patient at risk for backflow.
Backflow can also occur when tubing is brought high and brought from high, like here's the patient laying down, it's coming down on the patient. So gravity and backflow can also occur when you're using high volume evacuation with slow volume evacuation at the same time. So if you're gonna do that, I'm not gonna say don't do that, but I'm gonna say if you're gonna do that, I want you to make sure you keep it low coming into the patient's mouth.
I don't want it to be coming high so that then gravity is, working. That's where backflow occurs, normally. And that just means that's, the patient is then sucking on whatever's downstream in that tubing.
And we've been talking about backflow for a minute.
Oh, this isn't new.
This is not new, but it's a new to so many people in dentistry.
So many, somebody on Facebook just the other day said, is it so hard for patients to close their mouth on the suction? And I was like, Michelle, there is a way around this because I got to tell you, having a patient close their mouth in the suction. It's for me as a clinician is convenient.
Yeah. okay. This is where I think those practical tips come into play because what we're hearing, I think there's multiple layers to this story, right? Yeah. We have, an issue with some of our vacuum pumps being older, not pumping, not pulling enough, which will increase your chances of backflow. We have, pumps and vacuum lines not being taken care of very well.
Oh, yeah,
Create which is, and we can dive into nuances of each one of these.
Yes.
And then we kind of have, maybe too many people using HPE at the same time when we weren't built out for that many people, especially since the pandemic, more hygienists are using high volume. And then we have the position, like you mentioned it being so much higher. And we have had a habit of saying, "Close your mouth." And I totally agree with you. It's very convenient. One, you're right.
It clean clears out all the fluid from that patient's mouth to some people just need it because they feel like you're drowning. They have airway issues. It's kiddos. They have a bad taste. There's so many reasons for that.
¶ Preventing Backflow: Tips and Devices
In the event that we do need them to close, what were those, solutions you were talking about?
So there are backflow prevention devices that you can use. They have them for both the slow speed, Mr. Thirsty, your suction, and they also have them for your high volume evacuation as well. There's a few different ones on the market. They make ones that are inline backflow preventers. They end up about three inches below the suction valve. I don't think I'm a fan of these for a couple of reasons. One is it's three inches below the valve. So three inches, you still have all that.
there's previously suction fluids in that six inches because you have the valve, maybe five inches, five inches for the valve, three inches. But my next issue with those built in ones is because it's something it's a static thing. How do I know when that flapper valve fails. Because it's gonna fail at some point, because that's just, biofilm and grossness and sludge And so how do I know at what point, it's not like it has a red light. I discourage use of those inline ones.
They do make disposable ones. So there's a couple companies on the market that make, one that, you just put in your suction and it has a little flapper valve. And if a patient closes down, it will not allow that to happen. And so that one time use only you throw away. There's another company that makes one that involves not only a backflow preventer, but a disposable valve, which is nice.
Cause if we got into the nuances of the suction valves, like first off, think about trying to actually disinfect that properly, right? With a wipe.
Yeah. We're talking about like the on off valve. Yeah. On off of your suctions. Yeah. Yeah.
So hard to do. If you read the instructions for use for your valve, it might actually tell you that you have to reprocess that between every single patient. Or, it might say once a degree. Michelle (2): At least at some point. Yeah, It will have reprocessing instructions, which, if you've ever tried to take apart one of those, I tried to in my office when I learned all this a few years back, and it was like a gorilla glue of biofilm, Michelle. I couldn't push the thing out.
I had to sit it in hot, hot water and let it soak. It's like soaking it, the pan that you burnt something in, you gotta let it soak. Yeah. And then you gotta scrub. Yeah, anyway, super gross. So there is a company that makes a built in backflow, device with a disposable valve, which is super, I, really nice from a, infection control standpoint. There's also another company that just recently came out, and I haven't used this yet, but there's an autoclavable backflow.
I have it.
You have it?
I have it. I have not used it yet, but it is from Maxel, I believe, which is a Canadian company. So yeah, I have it and I'm going to try it.
Okay. I can't wait. I can't wait to hear. You like two little pieces. You autoclaved the pieces and the little flapper valve is disposable, but it's only the little flapper valve. So environmentally, what a lovely idea. And it comes in pretty colors, which makes my heart happy because I like that.
That's true. We love a color coding system.
I really do. so those are some of your options For preventing backflow at the patient, like that's at the patient level. Then a patient can go ahead, they can have their make out session with Mr. Thirsty. They can, comfortably get the toxic fluids out of their mouth. They're not toxic fluids, by the way. But anyway, patients think so. But to me, Michelle, you know how we talk about hierarchy of controls when we talk about infection control and PPE is the bottom, right? PPE is our last resort.
I almost feel like that these backflow prevention devices, while crucial, like you should have one, right? and you want to talk about an easy way to market that to patients, tell them about backflow, they'll be like, oh yeah, I want that, because that's gross, right?
So gross.
If you're not using infection control for marketing, But feel like those backflow devices are your PPE. That's your bottom. That's your bottom of the pyramid and doing things like you just talked about, which, we can dive into talking about making sure your vacuum is the right size, making sure you're doing that maintenance so that then that decreases your chance of having backflow and making sure that your lines are clean.
That's actually I like that analogy because I do talk about the hierarchy of controls quite a bit. So PPE being the least effective. I like that. And, but then here comes the work practice controls, which is the hardest I think, cause that's our behaviors and that's telling people not to close their mouth, but then actually taking care of the units are going to be your bigger picture here. And you and I have graduated many a year ago. So we've been doing this a minute. Decades. I joke.
I was like the only graduating fetus ever in hygiene. So still very young, but still been doing it for 25 years. Yeah. Weird. But we, I know not weird at all though.
¶ Cleaning and Maintenance of Suction Lines
So I talk about like, how I started with a bucket of soapy water and that's how I cleaned my suction lines. And now we know so much more.
And now we know so much more. So we had that bucket of soapy water and where we did the plunge and slurp method, You plunged it in and then you put it at the surface and let it, and then you plunged it back in again. And when I talk about that, I often, I use the analogy, have you ever driven with somebody that's learning to drive stick shift car?
Great analogy.
And you're like the, that's what's happening because they're trying to figure that is what your vacuum is doing. It is while you're doing that plunge and slurp to your vacuum, it's not good for your vacuum. So first off, it's a lot for your vacuum. It's almost it's like doing a beer bong. I feel like I'm ... Michelle: a lot of fluid at one time.
It was a lot, but also What's happening with the plunge and slurp method and the bucket method is that fluid that, that, that solution that you're using to clean your lines. Gravity is just holding that solution at the bottom of that line as it goes across. Where you and I know we both really are in favor of an atomizer. So something that you stick your tubing to and it brings up air and the fluid and the solution at the same time.
And then it creates this like this little tornado vortex inside the line. So it's actually cleaning all 360 degrees of the line, not causing your vacuum to choke because your vacuum that is getting that solution and that air at the same time. So it's okay, I can do this. I can drink this. And the super bonus, Michelle, is using these atomizers, it's hands free. I can pop it on, let it go, and type up my notes, or disinfect my room, or do whatever I need to do.
I'm not sitting there plunge and slurping. And many of them actually, will stop all by themselves when it has the right amount, like, when it's sucked up the right amount of stuff.
Yes, my little ADHD heart love that version because I can walk away and finish cleaning my room and all the things.
And ideally, you actually want to, after you're done, after it's soaked up the right amount of solution, you actually want to let some air go through your lines for a couple of minutes.
Yes.
You actually want that to happen because you want it to travel all the way to the vacuum, wherever that is. And so this is a great way to be able to do that again and not be like, I don't know, just standing there holding them on or whatever you're doing. and so you can just do that and get more work done. So an atomizer hands down, get it hands down. I didn't even mean that, but that was good. yeah, you should definitely be using an atomizer at minimum daily.
Yes.
To clean your lines at minimum. And if you have really bloody, you had a super like bloody non surgical periodontal therapy. you know what I'm talking about, right? You're like, it's a murder scene.
Yeah.
Oh, I would highly recommend running it in between patients. Cause again, think about that chance for backflow. I think the CDC says one in four people experienced backflow. Is that what the CDC says?
I think so. And that makes me.
So think about that, particularly if you had something that was a really bloody procedure. think about what you would want. Would you want to know that was still like inches away from you? Or would you want that to be flushed through? I want that to be flushed through.
Yeah, and I ha I went into an office one time and had a, cleaning for the first time ever. Because who does a hygienist's teeth?
And That's just between 24 and 25 with my Montana Jack, right?
honestly, I was like, I know there's so much coffee stain everywhere. I need it off of my teeth. I can't. I've done what I can do here. I need that. And. I remember her going, okay, close. And I like just literally took the suction and just went, and she's oh, you've been close. I was like, oops. I'm like, why does anybody ever let me in anywhere near that? 'Cause I'm like, absolutely not. That's disgusting. Excuse me. Sorry. That was a really ridiculous reaction. . Yeah. Let me tell you why.
I was like, absolutely not. I would not. It's so icky.
¶ Challenges and Solutions in Suction Systems
You know the other thing too that I learned, along the way here is that when we put all that water, like we have a lot of right angles in our plumbing and when we are, and not just that you're like your lines at your dental unit, cause that's where I thought that's where it started and ended for me. What's right here in front of me that I can see. But the reality is there's so much like in the floor, up the wall, in the ceiling.
Yeah,
That we have to manage. And that's not let me just call the plumber. this is ripping out plumbing tip.
Oh, that's jackhammering up the floor.
And I can't imagine. To talk about not getting a bonus that year. Right?
Yeah.
So I didn't realize that when we put all that water and that fluid through and it hits that right angle, literally all that slush that we are sucking up, right? Just stops there. And it Like dead ends. And that's where we start to see some of that clogging there, which I thought was, I was like, Oh, okay. It's not just these two that I touched.
I'm wondering, Michelle, like post COVID, when all of a sudden, like we started using HVE, hygienists, we meaning hygienists, cause I'd never touched the HVE. I was always just saliva ejector. Fine, right? Then all of a sudden, Oh, aerosols. Oh, I didn't know about that. You guys.
Okay. And then we started grabbing the H V E. And, when they came in and designed offices, they, looked at, doc op, they did the math, the suction math and the suction math look okay, doc op H V E doc op H V E hygiene up. We'll only we'll we're only considered half.
Right.
There's so many places I could go with that, but I'm not going to. But, and so we were only considered half in the map. And so now that, I was using it and Karen was using it. And then, Jim was using it in his room. Like our suction, our vacuum just didn't have the capacity that it needed to have. And so I would encourage anyone, if they're replacing their vacuum or they're, doing a remodel or maybe building a new office, Really do the math for everyone to have the ability to use the HVE.
Because, if you have more, that's better than having less. Because it's terrible, early COVID, I would turn on my HVE and Karen would turn on her HVE and our standard cubic feet per minute went down to one. There was no sucking happening. It was like, nothing was going on.
Nothing. No, I totally understand that. Okay. And I would even say even back in the day when I used Slive Ejector, I always knew when someone turned on their HVE in the office, because mine would go down to a gurgle.
Right.
Which happened to me recently in an office and I was begging them to do their daily, suction maintenance and they just were like it's fine on Thursdays and it finally got to that gurgle like I knew next door when they turned their HVE and I was like listen I'm gonna tell y'all right now this is not just for saliva and fluid this is aerosol management and I demand proper aerosol management. Call me a diva. Call me what you want. But I'm not breathing in this stuff, please. And thank you.
Nor do I want the next patient. So we started doing suction line mate. I was like, but don't you want to like, it's going to be so expensive.
I got to tell you, this is doing that maintenance. I know you're like, does it really make a difference? It really actually does. And I, coming out of COVID, I had, Robbie, he's our rep from Air Techniques, Bobby from Air Techniques came to my office and we tested the vacuum and we tested the standard cubic, feet per minute SCFM. And we did the valves and we turned on Karen's and, it plummeted and all that stuff.
and so I said to Robbie, like "Robbie crap, do we need a new vacuum?" And Robbie's like, Hang on, hang on. Let's do a couple things first. And thank goodness, because Robby only had the benefit from me telling the doc we needed a new vacuum. But Robby's no, it's great.
¶ Daily Suction and Chair Side Traps Maintenance
So the first thing he said was, okay, are you guys running your suction daily? And I'm like, I think we run it weekly with a bucket, right? And he's okay, daily suction with the atomizer. So that was one. Number two was we opened up our chair side traps.
Oh, that's another point that we need to get to, are the traps.
Oh, they were so gross, Michelle. there was no air flow through those traps. They were, ugh. he's okay, every week, you gotta change this chair side trap. and he's and in the beginning, you might have to change it more often, because you're gonna, you're gonna clean extra sludge right in the beginning, right? Yes. so first everyday suction next clean, those chair, side traps week, at least weekly.
¶ Vacuum Canister Trap and Tubing Replacement
And then we walked over to the vacuum and we looked at the canister trap and he's like, "When was the last time this was changed?" I was like, I don't know.
Most of the people don't even know they existed. Right? So never.
Yeah. So we unscrewed this thing and it has a metal, it has a, like a metal kind of thing in it, like a mesh thing. And you. You're supposed to see through it and you really couldn't. And so you talk about so you were losing air flow from, from the trap, from the chair side trap, right? And then we're losing air flow from the trap in the vacuum. And so we change that up for our vacuum, the instructions for you change that monthly.
So monthly we should be unscrewing that and then changing that out and putting a new one again, increasing that airflow, and making a real big difference. And then the last thing that we did, was we changed our tubing, our suction tubing and our suction tubing\, I think was 30 years old. Maybe 40. I have no idea. Literally when I took off the slow speed tubing, I have a video where I bend it and you can barely even bend the tubing.
Because not only is there stuff inside, but our disinfectants on the outside really, start to, affect those, that, that rubberiness.
Yeah, I know exactly what you're talking about.
So I changed out all of our tubing and per your suggestion, actually, I, I changed out the HVE tubing to that really lightweight tubing.
Yes, huge difference. I think you and I have both gotten it from that A Flex assist. A Flex, yeah. And yeah, night and day. It's like clouds and cement blocks.
It is. It is. It's clouds and cement blocks. You pick that thing up, particularly if you're trying to figure out how to incorporate HVE. I think eight feet of it weighs like, Oh guys, you'd have to Google it. I'm going to get it wrong. Like six ounces. I don't know. Something crazy. Something so light. and it's funny cause initially I only did the hygiene ops and the assistant Stacy, she felt our lines and she's Will you do mine too? And so I did and changed hers.
And as an assistant, even she was like, Oh, this is so much better. It's so much nicer. So anyway, so we went, so we started daily suction, changed our chair strike traps weekly, change the vacuum trap monthly and changed out the suction tubing. And we went from 5. 7 SCFM standard cubic feet per minute. That's the air and the vacuum that comes through at the same time recommended in the U S is 7. 1. We went all the way from five point, what I just say, 5. 67. We went up to 7. 3.
Just for little simple changes,
Just those changes. Just doing the proper maintenance.
I would imagine then increases the life of the actual vacuum pump itself, which is another huge investment.
Absolutely. So making those, and those were all easy changes, Michelle. Like I, this is, that was not a capital investment of anything. The tubing, I changed myself. We didn't even have to call in a, a service tech. I did it. You just pull it off and pop some back on and measured it. Easy.
Yeah, I agree. And I would also comment that not every single vacuum pump has that filter. You need to go find it though. Amanda (2): Yeah, Because I've been in there looking like where is it? And it didn't exist. Make certain ones like dry pump versus wet pump. those are different. And so some have them, some don't. So don't be like shocked if you don't see it. However, if you got it, you got to be changing it. Like it's going to make a huge difference for you.
¶ Amalgam Separators and Hazardous Waste Management
And then I think the other part of this conversation are the amalgam separators.
Yeah.
Because that also has decreased for a lot of people, the, flow, which was something that was mandated back. I think you and I have talked about this before. It started, like it was told to us in 2017 and then got mandated, like you have to have this by a date. And I think it was like 2020 or something.
It was 2020.
Yeah.
Because people were like, wait, aren't they going to extend it because of COVID? And people were like, no, you had enough.
We've had three years.
Like you, you Amanda (2): knew. You knew this was coming. You knew this was coming. You knew this was coming.
This one's exactly so we do have to have these amalgam separators or some kind of capturing device. Yes, an amalgam capturing device procedures. And you and I have talked about this before, as far as how do we manage our amalgam separator and how do we even manage our traps and what are our other solutions?
Yeah, so there's a couple things when it comes to your amalgam separator. One, do not believe your well intended sales rep who is, who has gotten information and they say information that they're given. Okay. But don't believe your well intended service or sales rep that says that your amalgam separator, you only have to change that trap once a year, Because just like any trap, you got to check it. And I highly recommend checking it with a UV flashlight.
If you stick a UV flashlight to the side of it, you will see actually where the fill line is because it's hard to see.
That's very helpful.
And they fill with prophy paste. They fill with, erythritol. They fill with powder, whatever they fill up fast. And a lot of people are changing those things every three to four months. And it really is. And once it's full, it actually starts to bypass the machine. And then you're just sending your amalgam waste water into the world, which is not what we want.
Not okay. Yes. Not okay.
That's your first thing for checking it and making sure, and when you change that trap for the love of Pete, I want you in full head to toe PPE. Wear full, frankly, I'd like you in a hazmat suit. I want you to really think hard about that. I want you with your heavy duty gloves that I know you hate. But, you are now dealing with something that is toxic.
Yeah.
That's why it can't go downstream. It's toxic. You were taking that thing off and you were breathing. And so I really want you to be careful if you don't, like some people bring in a service tech to do it. Great. Let the service tech do it. But if you are doing it, I want you in full head to toe PPE. I want you to take that one seriously because that's, that is not safe for you if you're not, you're not prepared.
But that being said, any trap, chair side trap, back to the chair side trap that we're changing once a week, any chair side trap that is in an operatory where amalgam is being removed, so if you're removing, maybe you're not placing amalgam, but you're removing old amalgam fillings, that chair side trap has now become hazardous waste.
Yeah..
And must go into your hazardous waste bin. It can't be incinerated, so it's not your sharps, don't put it in your sharps, don't put it with your bloody gauze, like it needs to go in its own little separate, you probably have a bucket.
That's like an amalgam bucket. Yeah, an
amalgam bucket. That trap actually needs to go in there because it can't be incinerated. because we don't want to incinerate mercury. Now, Michelle, there is a workaround to this. And I gotta tell you, there's a lot of people that are getting rid of their amalgam separators because of all the reasons I just said. They fill too fast. They're toxic to change. You got to deal with, the bucket and all that stuff. And there is a handheld amalgam separator, which complies with all the EPA regulations.
Not a problem. You can register it with your state. Easy peasy. And it's really cool because it just, it's a suction tip, but it has a capture device in it. And it actually then filters the amalgam and actually does a better job than your amalgam separator does. And it holds that amalgam for you. And then you just take that amalgam, handheld amalgam separator, and you put it into the recycle box that it comes with, which I did just find out Monday. If you extract, teeth with amalgam,
Yeah.
How teeth with amalgam have to go in hazardous waste, right? Yeah. They can go in your box with your handheld amalgam separator. They can go with your capital box.
That is a helpful little tidbit. Yeah.
Yeah. Just learned that because I was giving an infection control lecture for an office that uses, it's called Capt-all is the name of the product. But the thing that I love about this product, Michelle, and I know that you like to, you're a little crunchy green, save the earth kind of, this product is 100 percent recycled.
The whole thing is amazing. You don't hear about that very often.
Cause your amalgam separator filter that's landfill, baby. That's landfill mercury hanging out. This thing gets completely 100 percent all the pieces taken apart, actually get sent to a couple of different places to get completely recycled, which just, I just I love that idea. So not only are you capturing more amalgam.
Yes.
At the source. So it doesn't have to go right. Capturing more amalgam at the source, but the entire thing is then being recycled and you are still compliant and you don't have to deal with that darn thing that already pulled out of your suction and major suction worse. You can ditch
The other thing too, is when we talk about those traps at chairside, we need to be wearing all of our PPE. And we've chatted about this before too, is I think you need to change your trap right after you do that amalgam procedure. Mostly because if I'm rando Michelle coming in on Monday and we're like, it's time to change traps, I might not pick through. What's in that trap and be like, that's Mercury. That's amalgam And not know and put it in the wrong bin.
So I think it needs to be done right after by somebody who just worked that procedure knows that this one is a special
Or just use Capt-all and you don't have to worry about it at all. Cause it never made it to your trap. It got caught right there.
Which so for anybody that's struggling with their amalgam separator there is a solution for them. And we know that all of these things combined can increase our risk for less aerosol management and backflow for our patients, right?
Yeah. And so this is about keeping you safe and keeping your patients safe.
Yeah. Anything else that we miss when we're talking about backflow and patient safety around and our safety around sections and aerosols and all of that jazz?
¶ Incorporating High Volume Evacuation (HVE)
The last thing that I would throw in there is, and we touched on this a little bit, but I want to reiterate it because I still don't, I don't think we're doing it, is right after COVID, we hygienists, we brought in HVE, right? We were like,
Hopefully
Right. Hopefully. but I got to tell you, if you brought it in, I got to tell you, I think many of our colleagues ditched it. And There are a lot of easy ways I promise you guys to incorporate HVE that are still ergonomically sound for you. Things like using a CordEze bracelet, which is a cord management system. So if you're doing a handheld high volume evacuation, you can hook the tube in there. Super nice and easy way to do it and take some of the strain off.
There's lots of, hands free ones that I love. Isovac is one of my absolute favorites. People love the aerosol assist.
That's the one I use, yeah.
Okay, my, hygienist at my office, I was at Monday, she likes, one of those suction mirrors. She likes the one by GoldenDent. That's her favorite. Okay.
Yeah. I've seen that one.
Yeah. And that one does actually have enough, openings to create enough openings to be considered HPE. Yeah. Yeah. It does a good job. so still try to incorporate HVE because no matter what, I know COVID is gone, but bird flu is coming, my friends. something's next. I'm just saying,
I'm just saying,
but even just regular cold and flu. We know that we're not aerosolizing patient's saliva, but we're still, it's all just, there's just stuff, right? There's still just stuff.
They're generally, water lines. They have a lot of hairy bacteria in there that cause problems that we know. We know we're aerosolizing that. And it's also good to have, good technique, too. Using one that, where you're close, so you're capturing as much of that aerosol spatter and spray versus it being, like, I don't even know where in the bio in the room, whatever. So I agree. if you have, if you've ditched HVE, I think it is incredibly important for us to get back to it.
It is one of those engineering controls that was created for us.
And that's way higher on the pyramid. It's up here.
And when we don't use it, we are asking our PPE to carry a burden it just never was meant to carry. And so we can't like, it's just, it's too much. we have to have all these other things in place to keep us safe and our patients safe.
¶ Conclusion and Contact Information
Amanda, thank you so very much for coming on.
Thank you for having me. Happy to talk suction,
Right? We're happy to talk about a lot of topics.
I know. We're a little weird. We're a little weird.
I would love for you to tell everybody where to find you, where they can learn more, maybe hire you, bring you in for consulting, whatever these days.
Absolutely. I'm try to make it easy. I'm Amanda Hill, R dh, so Amanda Hill, rdh on Facebook, on Instagram, on LinkedIn. If you wanna email me, it's AmandaHillRDH@gmail.com and my website is AmandaHillRDH.com.
We love the synergy. Excellent. I know well. Thank you so much and we hope you guys enjoyed this and learned a little something about backflow and your aerosol management with your suctions. and definitely check out Amanda and all of her fun content.
Thanks, Michelle. ! Yeah. Yeah. Yeah.