Eye Safety in the Orthodontic Practice

– Hello, my name is Alison Werner, and I’m the chief editor of Orthodontic Products. Thank you for joining us for today’s podcast episode of “In the Sterilization Room with Jackie,” where we talk to infection prevention expert Jackie Dorst about what you need to know to keep the orthodontic team and patients safe during the COVID-19 pandemic and beyond. For over 30 years, Jackie has been a consultant specializing in instrument sterilization and infection control and prevention in the dental setting. She has degrees in microbiology and dental hygiene. Has been a featured speaker at the American Dental Association and the American Association of Orthodontists. Now, today for our topic, we’re gonna be talking about eye safety in orthodontics. And joining us to offer her expertise is Dr. Marie Fluent. Dr. Fluent is a graduate of the University of Michigan School of Dentistry. Her dental career spans 35 years, and includes roles as a dentist, both as an associate and a practice owner, infection control coordinator, office manager, and dental assistant. Additionally, she has extensive experience and expertise as a clinical instructor, educator, speaker, author, and consultant. Now Dr. Fluent’s focus is improving dental infection control and patient safety. Through her writing, webinars, and invited lectures, she has educated thousands of dental professionals and students nationally and internationally, and she has written numerous articles on infection control in the dental setting, OSHA compliance, and responsible antibiotic prescribing. She serves as the education consultant for the Organization for Safety, Asepsis and Prevention, otherwise known as OSAP. Marie, thank you for joining us today, and, Jackie, great to see you.

– Hi.

– Thank you for inviting me to attend this. It’s an honor to be here.

– Great, well, Jackie, you and I had talked about Marie’s presentation at the recent OSAP meeting. And you recommended that we do an episode on this topic. Why do you think orthodontists need to know about this?

– Well, Alison, as I was listening to my dear friend, Marie, and colleague talk about eye safety in dentistry, it came back to me, “Oh my gosh. So much of this information is significant for orthodontic offices and the risk that they have for unique eye injuries as they provide clinical care for the orthodontic patients.” So I thought, “Oh, it would be so helpful to all of the viewers to hear what Dr. Marie has to say, and how we can work safely and prevent those potential eye injuries in the orthodontic practice.” So I’m gonna let you ask Dr. Marie Fluent, my good friend and infection prevention colleague, go through what we can do to help orthodontic practices.

– Great, well, Marie, let’s talk about where you developed your passion for this topic. Now I know from talking to Jackie, it comes from your own personal history. Can you tell us about that?

– Yes, I’ll just give you the nutshell version. And I wanna be clear from the beginning that I have an eye injury or an eye disease in my left eye where my left eye is blind, but I need to be clear that it has nothing to do with being, it’s not occupational related at all. It was a stroke type of injury where the lights went out on my left-hand eye. But my passion stems from that, because it really stressed to me that we’re only granted one set of eyeballs in our life and we must do everything that we can do to protect them. And there are numerous sources of injury that may occur in the dental setting or orthodontic setting and we have to protect them. And when you lose your sight, it’s very, very emotional. And for me, it cut me to the core, almost like the death or loss of a loved one. And with that passion, I developed a passion for eye safety in dentistry, and that’s what compelled me to develop this course and really research eye safety in dentistry.

– Wow, well, that’s yeah, no, it’s definitely a passion for you. Now in your own dental practice, you actually had an incident where an assistant experienced an eye chemical exposure incident. What happened there? And was this before or after you had had your experience?

– Well, it’s before my eye experience. And, by the way, I just wanna tell you that with my eye injury or my vision loss on my left-hand side, it put an abrupt end to my clinical career, I was done. All of a sudden, I could only see out of the right portion of my loupe and I have no depth perception or a visual field. So it put an end to my clinical career and that was very sad too. In my own dental practice, before my injury occurred, while I was still practicing, a kooky thing happened with my dental assistant. She was not wearing protective eyewear at the time, and that is because she did not expect splashes or sprays to be generated. She was not being exposed to potentially infectious materials, or bloodborne pathogens, or flying debris, so she was merely setting up the operatory. And what happened is she took a cannula of etchant, which is 35% phosphoric acid, and a little clump of etchant, if you will, was clogged in the cannula. So she pushed, pushed, pushed, squeezed hard enough for etchant splurted on out and, of course, went right to her eye. And that was pretty scary, because it was completely unexpected. And what we did is immediately took her to the eyewash station. Fortunately, my office was very compliant with eyewash stations. And the OSHA mandates are that it’s easily accessible within 10 seconds of a walking distance from where the injury should occur to the eyewash station, that the temperature is tolerant, and then you flush your eye out for a good 15 minutes. And she thought that was overkill. And I remember as the washing procedure was occurring, she said to me over and over again, “Are we done yet? My eye feels fine, can we go now?” And I said, “No, we’ve got five minutes. We’re only at 10 minutes,” and at 15 minutes I let her stop. And then, I still proceeded to have her follow up with the local emergency department anyway. I was able to retrieve the safety data sheet on our local etchant, make a copy of it, sent her with buddy, another team member from the office, who drove her. And then, the ER physicians were able to look at that chemical and determine what treatment, if any, was necessary. Fortunately, as it turned out, we flushed the eye enough and they determined no more treatment or no further treatment was indicated, and she was A-OK, phew. But it was a close call and scary for me.

– Yeah, well, I know, Jackie, you and I talked in the last episode about the need for an eyewash station. And you actually talked a little bit about this, not Dr. Fluent’s case, but you used an example that was similar to that, so yeah.

– There is a need to routinely check the eyewash stations, ensure that they’re functioning properly, and, as Marie said, that it’s tepid water. It’s even specified in one of the ANSI standards that it should be between 60 and 100 degrees Fahrenheit and that it can deliver that for 15 minutes, as Dr. Marie said. So there are some regulations on both the safety equipment for accidents that happen and having it within a easy, accessible distance.

– Yeah, definitely. Well, Marie, let’s drill down. Let’s talk about, what are the significant eye injuries that the orthodontic team are at risk for? Now I know you gave me a list. So let’s start with the first one, which is clipping wires. It happens daily in the orthodontic practice. So what should the orthodontic team know about that?

– Well, orthodontic wire is considered sharp, and if you clip that wire, it can fly off in every which angle, including your eyes. So you need impact resistant eye protection to protect against that. And I’m gonna stress over and over during our talk today that personal eyewear, personal glasses like I’m wearing now, are not considered PPE. You’ve got gaps around the entire perimeter and debris can fly in it every which angle. So protection is needed, and clipping wires is one such example. They may or may not be contaminated. You may have tried them into the patient’s mouth, may not have, but either way, there’s a sharp tip on that and they can go flying.

– Yeah, okay, well, the second one is chemical adhesives, especially acid etch.

– Right, and we already talked about that, that you’d never expect accidents to occur, but they do occur, like what happened to me in my office. And OSHA does mandate that anytime you are handling chemicals or expect splashes or sprays to occur, then you need to have your protective eyewear on. And that incident that occurred in my office, even though I didn’t expect splashes or sprays to occur, it changed my office policy. From that point forth, when you’re setting up the operatory, you need to wear your eyewear.

– Mmm, okay, okay. And then, debonding procedures. Now that happens every day as well, so let’s talk about that one.

– It does, and I’ll share with you that I’m undergoing Invisalign myself. And so I’ve already been through bonding and debonding procedures, and that’s very similar to operative procedures in the general dental office. That you’ve got a high-speed handpiece that the turbine can turn between 400 and 450,000 RPMs. And knowing what I know as a dentist, that my eyes were at 16 inches from the patient’s mouth. And I know that because I was measured for loupes once upon a time, and that the debris composites or any type of dental materials, or even a dental bur can fly at you at 60 miles an hour at that distance. So you don’t have time to duck, put up your hands, get out of the way. If you’re gonna be hit, you’re gonna be hit. And you better rely on your personal protective equipment to protect you.

– Yeah, definitely.

– And debonding procedures, as I went through my first debonding with my Invisalign procedure, there was composite materials flying around and I could feel it hit my face here and there.

– Oh, okay, well, then I’ll ask this question. I have a follow up question that I’ll ask a little bit later. But let’s talk about frequent cure light use. Now I know that one you have a lot to say on.

– I do have a lot to say on that, and it’s an area where I’m becoming very, very passionate about it. Dental curing lights through the years have become more and more intense. And, of course, anything in dentistry and orthodontics, we want it quicker and easier. And that means more powerful lights, and light curing units, and getting into dental materials and the wavelengths is a little bit beyond the scope of this talk today, but I can say that the average wavelength of blue light is in the 400 to 500 nanometer range, and that is the most dangerous range for blue lights. Now some of our dental materials cure at a higher point in that range and some cure at a lower point, depending on the dental material that you’re using, and I won’t get into the gory details. But what you need to know is that whatever dental material you are using, it is best to match the curing light with that particular dental material, so that it will surely cure that and cause the photopolymerization of the dental material, and then it’s best to match your protective eyewear with the curing light that you’re using. So ideally if you’re purchasing dental materials through a certain manufacturer, you buy the dental material or the composite that you’re using, and the gel, and the bonding agent, that is compatible with the curing light, that’s compatible with the eyewear. If you buy ’em all separate, you don’t know if they’re compatible or not and that’s kind of scary. So, for instance, you can go to your local box store, and I’m not gonna pick on Walmart, but I just happened to see some Walmart curing light glasses for $10. Now will they protect against your curing light in that range and that intensity? I have no idea, and they’re not FDA cleared to prove that. And so you’re just taking a big, old risk. And let’s go back a little bit that these light curing units, they expose us to more blue light than we’re already exposed to. And on a day-to-day basis, we all have read this in the news that we’re exposed to lots of blue light in our daily lives. Whether it be street lights, headlights from a car, computer screens, personal electronic devices. And then, we switch over to the dental office or the orthodontic office, we’ve got our overhead lights that are LED lights, our light curing units. And if you’re wearing loupes with a headlight on it, that also is a LED light as well. So we’re just bombarded with blue light. And with a little bit of blue light exposure, it can lead to headaches, eye strain, a little bit of dryness in your eyes. But as you are overexposed to it chronically, and keep in mind that damage caused by blue light is accumulative. It just doesn’t happen, and then you’re cured from it. The damage accumulates over a period of time. it can lead to macular degeneration type of symptoms where you can actually lose the central portion of your vision, similar to my eye, and that area can be gray, black, or blurry even. And once that happens, it’s completely irreversible and you’ve got it for life. So it’s very, very important to understand these blue lights, especially curing lights, especially the intense blue lights that we are exposed to today.

– Yeah, no, definitely. So let’s talk then about what kind of eye protection is regulated by government agencies?

– Well, let’s back up two seconds, ’cause there’s several ways that you can protect your eyes from blue light in orthodontics and in dentistry. Manufacturers can provide goggles that you wear that are compatible with your curing light. There are little cones you could put onto the tip of your curing light. But the problem with those is that they can become dislodged, or you can have scatter radiation underneath it. There are paddles that can be used that the assistant may hold in place for the operator to perform the curing function. And then, there are little shields that you can attach to your curing light as well. The problem with the little shields are that they may protect the operator or the assistant, but not both, because everybody’s sitting at a different angle. The best option if you’re operating alone, would be the amber-colored goggles that are included with your light curing unit. And consult with your manufacturer if you have to buy something aftermarket to make sure it is compatible. And then, another option that is not recommended at all, is the look-away method. And that method you hold your curing light up, you look away, but inevitably you sneak a peek here and there to make sure your curing light is located where it’s supposed to be located. Don’t laugh, it happens all the time.

– A lot.

– Your eyes are exposed to that intense blue light, and as I mentioned, it’s accumulative. So I don’t recommend it. Don’t do the look-away method at all. Your best bet are the amber-colored goggles that are supplied with your curing light that is compatible with the dental materials that you are using.

– Are those goggles one-size fit all or does each member of the team need to have something?

– Well, it depends, try it on and see. And I would experiment holding the light curing unit, look up and down and make sure that you are protected from all angles. And if you have major gaps around the perimeter, then it’s not a good size for you. And I also wanna stress that your patients should be wearing amber glasses as well, especially if they are a child. Children are more photosensitive to the blue light range, and patients who are on certain medications that might be photosensitizing would be more sensitive as well. And these would include estrogen, tetracyclines, antihistamines, and there’s a list of them that your dental personnel should be aware of. And for those patients in particular, some type of amber protection would be recommended. And, of course, protection in general against flying debris.

– That’s the question I was gonna ask for the requirements for patients with like the debonding procedures where you said where the composite is flying around.

– Exactly, exactly. And patients should be provided protective eyewear to be worn during all phases of dental care. Silly things can happen. Etchant can fall all in a patient’s eye. There was one case that Jackie and I know about that occurred in a different subspecialty of dentistry during an endodontic procedure, where the assistant and dentist were passing a syringe and the contaminated syringe needle fell into the patient’s eye. And who expects that to happen? You don’t, that’s why it’s called an accident. And that’s why protective eyewear should be worn for patients in all phases of dental care.

– Okay, okay, so then let’s go back then to what is the eye protection that’s regulated by government agencies? What should practices be doing?

– Well, CDC recommends protective eyewear against splashes and sprays, and potentially infectious material for the dental provider, meaning the dentist, the assistant, hygienist, whoever is involved in clinical care, and patient care. OSHA is mostly concerned with the employee health and safety, so they do not specify eyewear for patient care. So that’s where we really need to be listening to the CDC guidance as well. And then, there are other agencies, standard studying agencies as well. And the one that comes to mind is NIOSH. There are NIOSH approved eyewear that is available and ANSI standards, A-N-S-I, American National Standards Institute. And they give standards that are recommended, how protective do your glasses need to be? What are the standards for the gaps around the perimeter? What is the impact resistance? What wavelength would they protect you against? They develop the standards for all of those. And the standards are updated regularly on a year-to-year basis. Our most recent standards were the ANSI standards. And you can read this inside your protective eyewear, Z87 point, and then you follow it by the year. So the most recent updates occurred in 2021 where we addressed the bottom gap in goggles. If you look up and you see a bottom gap, if it has ANSI standard 2021, it is a little bit more closed on the lower portion and provides a tighter seal around the perimeter. So each year we might see updates. But, in general, if you have protective eyewear that is stamped and labeled on the inside of the arm, that has the ANSI standards Z87 point and fill in the blanks, those provide adequate protection for you. And, like I said, personal eyeglasses, not protective enough.

– Right. Yeah, so what if someone requires glasses?

– Well, OSHA mandates that if you wear prescription lenses, that the employer provides two options for you to incorporate prescription into the protective eyewear or to provide protective eyewear that can fit nicely over your prescription lenses, and most offices choose that. Now the orthodontist office that I attend, I shared this in my handout. So if you have access to my bootcamp handout from OSAP, look at the final slides. This was my orthodontic assistant and I saw her glasses and I went, “Those are awesome! Let me see them,” and she did. She shared them with me and let me take her picture. And sure enough, they have the ANSI standard stamp, the Z87 stamp, on the internal component. They have a closed bottom gap, they’re closed around the perimeter, they have adequate side shields, and her prescription lens is incorporated into the design of them. And there’s a little bit of padding on the forehead portion, so it fits nicely against her forehead. And they’re comfortable, they’re clear, they’re non-foggy. And if you add those up, she’s compliant. She wears them, and that’s the bottom line. If they’re uncomfortable, if they fog up, if they scratch easily, people are gonna say, “Mm, why bother? I don’t wanna deal with this.” But if they are comfortable, clear, scratch-resistant, lightweight, and incorporate the prescription, you’re more likely to be compliant.

– Yeah, okay. Well, it sounds a little bit like our discussion about N95 masks, Jackie, where we were talking about like, if you’re not comfortable with one, go try something else until you find one that’s comfortable so you’ll wear it. So, yeah.

– Yes.

– Well, Marie, I know you coauthored a paper in JADA on eye safety. Can you tell us a little bit about that paper and where our viewers can find it?

– Sure, I was honored to be the lead author of this, honored or chosen, I’m not sure what you would categorize it, ’cause it’s a lot of work, it’s a peer-reviewed article. But the article, it’s titled, “Shedding Light on a New Hazard in Dentistry: Light Curing Units.” And my coauthors, and really the process of writing is more exciting and impressive than the final outcome. ‘Cause collaborating on this article was Dr. Jack Ferracane, who is one of our leading experts on dental materials. And he taught us a lot about the actual chemical cure, how it occurs, photopolymerization. Dr. Richard Price, who was our leading world expert on light curing units. Anything you wanted to know about a light curing unit, there he is. Then we brought in Dr. Mace, who is a leading clinician in the Missouri area, and he addressed the need, during clinical practice, this is what we’re up against. And then, finally to complete our group, we brought in a retinal specialist, a physician, ophthalmologist from the University of Michigan Healthcare, who taught us about retinal damage, particularly related to blue light. And she kept us on track with the current literature with blue light and what damages actually do occur. So the process of writing this article was very, very fascinating, because we addressed this from a multidisciplinary approach and everybody added their two cents. And my passion, of course, comes from my own personal history and from infection control and safety perspective as well. And I have more familiarity with the regulatory agencies that impact patient safety and infection prevention. So all of us put our heads together and formed this article, and then talked about light curing units. And I gave you the nutshell of the article, but of course there’s a lot more details in the article itself. About how to cure safely, what you’re looking for, how to ensure compatibility between your dental materials and the light curing unit, what we’re looking for in eye protection measures, what works, what doesn’t work, and tips for curing lights. And it’s all pertinent to the orthodontic setting as well. So this was published in August, 2019, kind of right before the pandemic hit. So, unfortunately, I think it kind of fell through the wayside because we had bigger fish to fry during the global pandemic. But it certainly is a topic that has longevity and something that will be pertinent in the years to come as well.

– Definitely, well, I highly recommend our viewers check that out. We will include a link in the notes below this if you’re watching the video version. Marie, thank you so much for joining us and for breaking this down for our viewers. I really appreciate it. And, Jackie, thanks for bringing this topic to my attention and inviting Marie to join us.

– Well, it was an honor to have you join us and thank you, Dr. Fluent, for taking the time out of your busy schedule for it. And I hope that in the future the AAO, or maybe one of the component organizations, schedules you for a comprehensive lecture on orthodontic eye safety, because you certainly have a wealth of information to share and protect our valuable vision. So thank you for today.

– Protecting your vision and our vision, I might add, pun intended. And I wanna thank both of you for the invitation to speak. It was an honor to be present. And I look forward to future collaboration and our paths crossing again, thank you.

– Thank you.

– Thank you so much. And to our viewers, check back soon for the next episode of “In the Sterilization Room with Jackie.” In the meantime, to catch up with past episodes or to check out the latest orthodontic industry news, visit our website, orthodonticproductsonline.com. Until next time, take care and stay safe.