How is Covid-19 shaping dental office design?

So I'm going to go ahead and begin. For those of you that are still entering, we will. The room will still be open, so you can continue to come in. I'm Jean St. Louis. Jean St. Louis Consulting. Thank you so much for coming. Just some usual housekeeping that maybe you have been on the webinars before, maybe you have not. One is we are offering CE for this webinar. So after your attendance, you will get a thank you note and the CE information will be in that thank you note. So be on the lookout for that. In addition, we will be having a polling at the end of the webinar. And it's just a fun exercise, kind of asking some questions, get a feel for who's out there anonymously. We don't know who you are, we are not tracking you, we're not going to stalk you, nothing like that. So please help us. It's just a fun exercise, especially in this time of lockdown. The third thing is on the lower level or on the upper level of your screen, you have an area that you can chat or you can ask any questions. Please feel free to do that. We would love to answer those questions at the end. So, Dale and Monica, I will in lack of distraction for you, I'm going to go ahead and I will put on my picture, but I'm right here and I'm listening and whatnot. Every so often I'll undo my picture, but I don't want to be distracting to you. So that's why I do that. I also will mute and all the attendees are muted. So attendees, your opinion is important. We want to hear from you. Please unmute at any time. You're welcome to again ask questions. No problem on that. So in addition, for those of you that are new to these webinars.

I do offer anyone that's attending the opportunity to have a COVID 19 baseline analysis of your practice. If you are interested, you know how to contact me. You know, feel free. Okay. So without further delay, I want to introduce our topic today. And that is how is COVID 19 shaping your dental office design? So what changes can you implement today to your existing practice as a result of COVID 19? The planning for the future. How COVID 19 impacts the dental practice design going forward and then beyond the office, how to give your patients and staff reassurance, which I know I've been on the phone with many, many practices this week and there is a lot of mixed feelings out there about assurance. I know. For instance, Dale and Monica are from the state of Illinois. And their governor came on Friday night and said, hey, we're open. You can have your dental patients. So Dennis, we're freaking out. Some are ready, some are not. So let me introduce our two speakers who are dynamic speakers. We've got Dale, who is the director of pre construction, and Dale Diner and Monica Smith, who's the Director of design. Dale comes to us as the director of pre construction at Apex. He leads the pre construction team which provides budgeting, scheduling and constructability services that seamlessly connect the design and the construction disciplines for all of Apex projects. He has 15 years of diverse construction experience and the results oriented attention to the detail assure that each Apex client of accuracy and accountability in achieving their vision within agreed cost and timeline. And then we have Monica, the Director of design. Monica joined the design industry in 2010 and quickly grew into the Design Director at apex design in 2014. With the team of designers she leads, Monica is able to translate the doctor's vision into functional design. Monica's understanding and adaptability shows each project to be unique, stemming from the client's inspiration. She also collaborates closely with the architectural and pre construction teams, ensuring that the budgeting and feasibility of the project is maintained. So let me, without further ado, introduce you formally to Dale and Monica. So go ahead, take it away, guys.

Excellent. Thank you. Jeanne, you're able to hear us all.

Right, we can hear you. Perfect.

Excellent. Thank you for the kind introduction, Gene. Good afternoon to you all. It's an honor to be invited to this webinar. Hope everyone is staying safe and well. What Gene's introduction doesn't do is tell everyone about the interesting relationship Monica and I share as we work together. With her being responsible for design and aesthetics and flow, and myself being responsible for clients budgets and ensuring buildability. It can create a bit of an interesting dynamic at times, can't it, Monica?

Yep, that's for sure. A bit of a push and pull, that's for sure. And you know that's coming from because Dale and I are both looking out for the best interests of our clients. But we're both coming from two very different directions. Like I'm on more of the aesthetic in the design side, so I'm always looking, looking out to maximize design and to deliver a really awesome project at the end of the day. And Dale here, we call him the eor the kind of fact checker here sometimes.

You know, he was really looking out for the best interest of the client when it comes to budgeting. So we'll have quite the back and forth to the Amusement of our clients here. And so, yeah, it's is bringing some good stuff to the table. But at the end of the day, we want the best outcome with the project at hand. So, Jean, you already introduced our topics very nicely, so I'll move on. And maybe we should have a little more of a kind of general introduction to this topic here with the fight that we're facing here. Dale, why don't you tell us a little bit more about who is our opponent here?

Yeah, I think everybody on the call is very well aware of what we're up against here. The coronavirus, which has not previously been identified, which is called SARS COV2 and causes COVID19. There's a lot of known and there's a lot of unknown things about what we're up against as to our opponent.

So, you know, just quoting some things from the CDC and the World Health Organization. We know that the virus is spread mainly through person to person contact who are in close contact with each other. It's transferred through respiratory droplets produced when an infected person coughs or sneeze or talks. These droplets can land in the mouths or noses of persons who are nearby and possibly inhaled into the lungs. We also know that COVID 19 may be spread by people who are not showing symptoms. And finally, we do know that there are ways to protect ourselves and our practices, which we'll cover more in detail shortly. Just a few unknowns here.

We don't know when we're going to see a vaccine. That's a big unknown.

You know, while testing is becoming more readily available, we're wondering if there's going to be a possibility for testing for dental practices. It would be ideal to see a testing station within a dental practice in the near future, but as of right now, that's an unknown. And while the curve is flattening in many states, we don't know if we're looking at a reoccurrence. So with these things in mind, we recognize that we need to treat every patient as infectious. And screening of patients will go on for a very long time until an effective vaccine is developed and most of the population becomes vaccinated. We will learn to live with the risk of COVID 19 in our daily life, just as we've learned to live with the awareness of risk after 9 11. Today's younger generation doesn't remember air travel without the TSA lines and all the different things that go through trying to get through security.

Just like today's babies may not know a world without major impacts of the Novel coronavirus.

Yeah. So with that, let's discuss what we can do and what changes can the doctors implement today to their existing dental offices as a result of COVID 19.

So let's break this down a little bit. What we'll do is initially we'll look at what sort of changes we can make from a visual perspective.

So let's look at signage wayfinding how we might be able to use our existing TVs and monitors throughout the practice. So post visual signs and posters at the entrance and in strategic places such as the waiting room to provide instruction about hand hygiene and respiratory hygiene and cough etiquette. If possible, implement one way traffic throughout the practice. Outside of instructing patients, what sort of reassurances can we provide the patients using our existing equipment? I mentioned the monitors and the TVs. You know, through the process of maintaining guidelines that have been recommended, we tend to forget that the patients are frightened and need reassurance about what your practice does to prevent the spread of virus. It could be something very simple like a slide presentation or a video that plays on TVs or your monitors throughout your practice that the patients can see. Perhaps it's something about the steps that you take to disinfect the op, or an internal cleaning checklist that you use for the practice. You could also have the monitors in the practice.

You could also have on the monitors in the practice something about the equipment or the partitions that you've installed or your new staff protocol you now use as a result of the coronavirus.

Another important aspect to think about is the provision of hygiene supplies for staff and patients. It's more important now than ever to provide supplies for respiratory hygiene and cough etiquette, including alcohol based hand rub with 60 to 95% alcohol tissues and of course, hand sanitizing stations located strategically throughout the office for the patient's use. Maybe we'll touch on physical barriers next. Monica, do you want to tell us a little bit about this?

Yeah, for sure. We have actually had quite a few clients call us up and ask, what can I do when it comes to physical barriers? And there are different materials you could use for panels. They could be glass or acrylic and you want to have a surface that's wipeable. But even a medical curtain would work. And there's different areas in the office that you might want to consider to incorporate these physical barriers. The first that comes to mind is of course a check in at the reception desk. So having a sneeze guard right there on the transaction top to Provide more of a safety for not only your staff, but also for your patient. And then having dividers between chairs, perhaps in the waiting room. Maybe your waiting room is not large enough to spread chairs six feet apart. So maybe you want to have dividers and a physical barrier between waiting room chairs. Then in open base, you could have an orthodontist office or pediatric office. You might have an open base setup and want to incorporate some of these physical dividers. Those could be freestanding. We've also hung some from the ceiling for some of our clients.

So that's definitely something that gives that reassurance to patients and staff. And then depending on the climate you live in, and as the weather warms up, you might want to consider to bring some of that initial testing or some sort of a triage station to the outdoors or even have outdoor seating in the beginning. And of course, you can keep your patients waiting in the car as well. But as your patients are coming into the office, having a triage station outside with a divider for privacy is another way to incorporate those physical barriers.

That's good. I guess what we should do is really walk in the steps of the patient. So travel the path of the patient. Take careful consideration into what the patient will be touching as he or she goes through the office. If you have a vestibule door, consider keeping it propped open. The same would apply if you have a door between the waiting room to the corridor. Think about the patients touching those door handles and the number of patients that you have going through those door openings on a daily basis. So keeping those doors propped open temporarily can help prevent the spread of virus. Encourage your patients to wait in cars where practical, and ask the patients to leave excess clothing and personal items in the car. Look closely at your existing furniture. Is it easily cleanable? Consider replacing couches or fabric covered seating with antimicrobial fabrics and textiles. And easily wipeable seating. It's also suggested that you remove toys, magazines and other related items from within the waiting room. So that really covers all the visual areas that or most of the visual areas that you could look at. Now let's look at some non visual areas that you could address. So first off, your ventilation system. We know this is a big topic right now. We know that within a dental office there's a lot of aerosol generation and contamination is very high, which is generated by ultrasonic air polishing air, water syringes and tooth preparation with air. The heating and cooling systems within the office can pick this up, this contaminated aerosol up and transmit it throughout the office. So on a temporary basis you could consider installing some portable solutions that create negative air pressure to try to exhaust the area.

And discharge that area. Direct that air directly to the outside away from people and air intakes. Or you could direct the air through HEPA filters before it's introduced to other spaces. In my opinion, however, I do believe that a longer term solution should be considered when looking at your ventilation system within your dental practice and we'll touch on that later. Another non visual is look at your work shifts. I was speaking to a doctor recently who has a two doctor practice with six operatories. He was planning on running two shifts, one doctor for three days Monday through Wednesday with a dedicated team and the other doctor Thursday through Saturday with another dedicated team. His reasoning was that it could minimize the risk of both himself and his staff and to his practice should someone become infected within the two groups.

Also consider your daily huddles. Use your morning huddles to provide a refresher on the protocol for PPE and disinfection procedures. Have protocol in place in the morning for staff when checking temperature and the necessary sanitation steps as they come in in the morning.

Look at your existing computers and phones. Discourage any sort of sharing of equipment and supplies, especially headsets that have been near the face and computer keyboards and mice. Move away from any sort of printing or paper handouts. Embrace digital technology. Instead of a clipboard, let's move to a tablet based system that can be sanitized each time someone touches it for check in or check out. The other thing you want to look at is lunch or any sort of eating that happens in the office. We suggest that you look at the staff breaks and lunches and perhaps stagger them or request that they eat in separate areas. Temporary partition could also be looked at in the areas where you would typically eat. Ask employees to bring food, beverages and that all important coffee from home rather than using the lunchroom resources. This could even include silverware and napkins if you don't have sanitary single serve receptacles for these products. And of course regulate that food that often gets dropped off or gifts that get dropped off as this can also be a source where that might be contaminated.

And the other thing that we want to touch on is teledentistry. Of course this is, you know, something that's new and I think it's here to stay. This is a digital age for dentistry. Teledentistry is a segment of digital dentistry that is rapidly becoming standard operating procedure. What's more, when we reopen our practice, we can use teledentistry to save time and help assess which patients are the first to see. Because we have a large backlog of patients requiring treatment, this is actually good news regarding the new normal.

So, Monica, with your experience in designing dental offices, how do you see dental office design being impacted going forward? For example, when you have a new doctor that might come to the table and they're looking at real estate.

What do they do when it comes to now, when it comes to looking at the size of what sort of office they should look for?

Yeah, thanks, Dale. That's right, because clients do come to us in early phases of real estate.

Endeavor and choosing. So they would. They might sometimes even come when they're looking at two or three different properties and trying to determine which one is the right one, which one is best and which one is the correct size. So when it comes to size, clients have been coming to us for recommendations in the past what size of office space they need for the new endeavor. We've been advising them to plan for approximately 350 to 400 square feet per operatory, which does include functions like staff areas and number of doctor offices and consultations rooms.

Now there's of course an efficiency of scale. The more arbitraries you're planning for, the lower that number of square feet becomes. So we'll touch on the next points some more in a bit. But we see future dental offices needing more space and they need more space for things like staff and patient flow separation for additional functions needed and for more dedicated workspace. So in the future, with that said, we're foreseeing spaces to go up to about 400 to 450 square feet per operatory.

So now that we've addressed size, let's talk about the shape of dental offices going forward.

Yeah, so in the past what we've seen a lot are retail spaces that are narrow and elongated rectangular spaces. So you see an example here on the slide on the top. These worked very well because they provided maximum efficiency with one central corridor. And operatories were often lined up on one side of the corridor with supporting functions and staff areas on the other. Today, and maybe in the future, we might favor much wider spaces.

That are allowing more for a horseshoe flow or a circular flow with separate check in and check out areas. So on the example below, I can't find my mouse. You can see there's separate check in and a separate checkout with a patient corridor here, but then a separation of staff areas down below and a staff corridor over here. So you don't want to have paths crossing as much maybe in the future. And you want to separate those clinical and patient areas from your staff and support areas.

So moving in from the inside out, what do we see when it comes to Parkingdale?

Yeah, that's good. So when we look at doctors purchasing real estate or buildings, oftentimes parking tends to be overlooked. It sometimes tends to be an afterthought. And it's only going to become more important, we feel, in the short term and potentially in the long term to ensure that there's increased patient parking for dental practices and specialty practices. So parking, while there's not an exact ratio that we can offer today, we do see that going up in the future.

What about the building structure and the envelope of the building itself?

You know, and again, this is another very important area as we see that there's going to be financial impact on the cost of constructing new dental practices in the future. And so it's going to be more important now than ever to analyze the building envelope or shell of the building to ensure that the building is airtight, structurally sound.

Now, as the director of pre construction, Dale, I think your specialty are the utilities. So what can you tell us about things like, you know, water, electric, H Vac?

Yeah, that's true. I guess I am known for digging around in old buildings and looking closely at the three main utilities within buildings. And that is like Monica's already said, water, electricity and heating and cooling, or as we call it, H Vac.

We won't talk so much about water service sizes or electrical service sizes today as we don't feel those will be too significantly impacted going forward as a result of COVID 19. What we'll talk extensively about is H vac. So there are a variety of H Vac systems that we see within dental practices. And the three and three different typical scenarios that we most often encounter are one, your typical retail setting, which utilizes a rooftop unit, also known as an rtu, a freestanding smaller building with your more traditional split system with the furnace inside and the condenser outside, more like what you would see with your house. And three, a multi story building which has a central system on the roof and individual VAV boxes within the ceilings of the different floors, distributing heating and cooling throughout the different floors. With all these different systems, it is all the more important to look at the factors such as the size of the space and these existing systems to ensure that we achieve the necessary flow rate. We want to see a minimum of 12 air changes per hour. Taking measures to improve ventilation in these areas are the rooms where someone was ill or suspected to be ill with COVID 19 will help shorten the time it takes respiratory droplets to be removed from the air. We mentioned earlier that we recommend creating negative air pressure and exhausting the air or running it through HEPA filters. So let's just touch on HEPA filters for a minute. HEPA filters are very effective and are certified to capture 99.97 of particulates that are precisely 0.3 micron in diameter. The coronavirus itself is 0.125 micron, but the droplets that it travels in when people cough, talk or breathe initially are larger around 1 micron. So the recommendation of using HEPA filters in a dental practice do assume that the coronavirus is within a droplet and not by itself.

Probably our most recommended solution within H Vac systems is the use of ionization, similar to what happens when lightning with lightning during a thunderstorm. The ionization process is a strong electrical field that causes the air around the cloud to break down, allowing current to flow in an attempt to neutralize the charge separation. Simply state of the air breakdown creates a path that short circuits a cloud or earth as if there were a long metal rod connecting the cloud to the earth. We recommend a system that creates needlepoint bipolar ionization, or nbpi, which is the artificial generation of both positive and negative ions that occur naturally without the production of ozone or byproducts. With NPPI does is it reduces or eliminates particulate pathogens, mold spores and viruses, and converts VOCs or odors. It also helps with energy costs because it reduces pressure on H Vac systems because of its removal of particulate. This technology artificially generates ionization in high densities to maintain between 1200 and 2000 ions per cc in our occupied practices, which would typically only see around 100 ions per cc. A good comparison of what you see in different environments is at the top of mountain you would see around 5,000 ions per cc. However, in a city you might only see around 200 ions per cc. This ionization, which flows into the air within a dental practice, will attach to the RNA and DNA cell structure, both airborne and surface pathogens. The pathogens are no longer able to exist. This product is proven to kill pathogens including E. Coli, MRSA, TB and Neurovirus. The system has over 300 installations worldwide and it's installed in many healthcare applications including hospitals, outpatient centers and offices. Also want to touch on there's been a recent influx of small units that have hit the marketplace that claim HEPA filtration or ionization. And it is now required that all electronic air cleaners pass a UL certification to prove that they produce less than 5ppp and therefore are deemed ozone free. There is no level of ozone that's deemed safe. Several brands of ozone generators have EPA establishment numbers on their packaging. And this number helps the EPA identify the specific facility that produces the product. The display of this number does not imply EPA endorsement or suggests that any way the EPA has found the product to be safe or effective. Another important point about these units and the standalone HEPA units is that most operate on six air exchanges per hour. We touched on earlier that we want to see a minimum of 12 air exchanges. They also don't produce enough ions for your space.

Another system that we see is UV lighting within H VAC systems and within rooms. And we haven't been able to really recommend UV light systems due to the potential risk to staff. Now, I know that the IDPHR here in Illinois did recommend a form of it recently.

However, from our understanding, we've seen from hospital use that it's been known to discolor surfaces over time. They also deteriorate filters and plastic wire coatings and insulation and will break down the coil coatings within H vac units. UV lights cannot reduce particular odors.

Another issue is that the placement of these fixtures or fans. These UV fixtures or fans would need to be optimized for the specific spaces. And the effectiveness has yet to be demonstrated within larger public spaces.

Very good. Thanks for a lot of information there, Dare. So let's talk a little bit about how we can plan out the space. So we talked already about what conductors do with existing space. But now let's move into planning out space as if you were building a new practice.

So no doubt there's going to be additional functions needed within dental office.

I think so. I think so. I think with the increased use of personal protective equipment or ppe, we will also see an increased need for higher capacity storage. You know, storage has become smaller and smaller over the years. But I think that doctors will find that they will need more storage now. And it's also important to note where that storage is needed because the staff entry will need to have storage adjacent to them. So when staff enters and they change and put a gown on, they will need storage and perhaps locker rooms. So those are. Another additional function is locker rooms.

So storage and locker rooms and then.

Perhaps the laundry area. So if you're using reusable gowns or scrubs, you Might need some laundry areas, or else you might want to look into a service that is provided for your staff with that.

So, Monica, tell me about how room sizes and room quantities are going to be impacted as a result of this.

Yeah, room sizes and room quantity. So a certain amount of social distancing might prevail post COVID 19, which will lead to planning of either enlarging the waiting room to allow for adequate distance between chairs, or sizing your waiting room way down if you're planning to bring your patients right into the treatment rooms, which will consequently increase treatment room quantities. So if you're not wanting your patients to wait in the waiting room and you're making that room smaller, maybe you need to plan when you're planning for a new office to increase how many treatment rooms you want to provide. We will also see treatment rooms to increase in size, as you might add functions in those treatment rooms, like individual sinks and perhaps family seating. So, you know, sinks have been going away over the years. We've been seeing either shared sinks like you see on this image here on a T wall. It's very convenient. But if we see treatment rooms becoming more private and maybe even closed, these things will have to move into the treatment room, making those treatment rooms a little bit wider. Another area that will increase in size is the width of the corridor. I'm pretty sure.

It will become important. Having the ability for two people to pass comfortably in the corridor will become a very important factor in planning the flow of your facility. And then, not to forget, allowing for space so that staff can change PPE before entering a different patient room. Somebody standing there changing another patient or another staff member needs to pass.

Then moving into, you know, what is the patient experience moving forward? You know, patients are scared and, you know, we need to calm them down in some ways. But also, what are we offering to our patients? You know, very popular offering over the last decade or so have been beverage bars. Now, beverage bars are touched by every patient. So is that something that we want to continue to do? Maybe in the future again, but maybe temporarily you want to consider more of a concierge approach. And what that is is, you know, reception desk that allows the staff to come out and help somebody or give somebody the beverage. Instead of everybody reaching in the refrigerator, maybe they're just getting a bottle of water handed to them.

And then, you know, we touched before on family seating. So what we mean by this, you know, of course, ideally, now that you're opening your office, you want families to stay in the car and not Come in. But as you're building an office and looking into the future, you know, we touched on waiting areas to become smaller. Well, what's happening with that parent that is accompanying the child, for example? So perhaps family seating is happening in the operatory instead of the waiting room. So again, having a little bit more width there and allowing for a family member to come in and have a seat or two is something we want to see. And then patient belongings and providing hooks in the operatories. I've been to many offices before where the patient is expected to just deal with their belongings and however they like to. And purses end up on countertops and jackets on floors or on the foot of the chair. This is something we want to really think through in the future is what is happening with patient belongings. Because those possibly contaminated items that are personal to the patient, like purses, we don't want them on countertops. Moving forward.

And then the next category here is how do we equip a space, a new space, post Covid. So definitely one thing that comes to mind is touch free fixtures. This is something that you can do in your existing office or planning in your future office is faucets throughout the areas that are touch free, that are motion sensored. This can happen like you see in the image here at the hand washing station, but also in all your bathrooms having fixtures that you don't touch. And it goes way beyond the fixtures. Right. If there's other products out there today that are touchless, you might want to consider those as well. So there's soap dispensers, faucets we've touched on paper towel dispensers that are motion sensored. And even more and more appliances coming out that you open with your knee or your hip or your elbow so you don't have to touch everything with your hands. And then one of my favorites is when the beverage bar does come back is these coffee lid dispensers that are touchless. And dysmotion.

Coffee lid dispensers that you see right in the middle down here on the image.

So those are those little small appliances and accessories. But there you mentioned before are doors and how doors could be propped open vestibule or between waiting room and the clinical side.

Doors really continue to be really in high traffic areas and continue to be touched. There's many ways we can go around the door handle. The image on the left looks like it has a door handle here. This is actually an oral surgeon that we built out here in Chicago. It has a barn door, a glass Barn door that you can just tip with your elbow, for example, and it will pull and shut close. So it pulls close. It has its own.

Ability to like to pull close. Other ways of closing and opening doors would be kind of a wave switch that you see in the top right here. Or a barn door can be opened and closed by foot. And standard doors could be also open and closed shut with your elbows. So there's lots out there on the market. So ask your design staff, you know, to incorporate something like this in your new office. Or some of these things can be retrofit in your existing office as well. So we touched on doors. Light switches are the next highest high touch areas where contamination might happen. There's motion sensors. I think we've seen them all. A lot of municipalities actually require motion sensors in bathrooms and in offices. And there's also another product out there that's a wave switch. So you just wave in front of it a few inches in front of it, and it turns off and on. We actually incorporate a wave switch like this in one of our offices here. It's an urgent care for kids, and triggering the switch with a wave actually frosted the entire glass front and door. So it made it solid and private for when a patient was in. But this urgent care was very much about not touching surfaces and touching as little as possible. So they incorporated those type of wave light switches throughout their entire office.

Beyond the light switches, we have trash receptacles and cabinetry throughout. Think about how do you open and close your cabinets? There's many different types of ways of doing that without incorporating hardware. So here in the image, we have a trash receptacle. You just wave your foot underneath this cabinet and the door opens and then you just tip it with your knee and the door pulls shut again. And this can also happen with cabinets. Upper cabinets can be operated by elbows and lowered by knees and hips. So there's ways around reducing the amount of cabinets you are touching.

Then dividers we touched on a few times. They can happen throughout the space between check in and check out stations in the waiting area. Those are other ways to equip a new space and really plan that from the get go when you're planning out your new office. Beyond equipping.

Well, I think we've covered a lot there. Tell us a little bit about how we choose our finishes when we build our new practices.

Sure. So when it comes to choosing finishes, finishes are everywhere. And you need to think about how you're cleaning these finishes. So when it comes to choosing a Finish, cleanability and the maintenance is of higher importance than ever. I think we've done quite a bit of research and have spoken to many of our manufacturers and material distributors about, you know, what can we clean our surfaces with? Post Covid and to summarize our findings, we found that a 2% bleach solution or 3% hydrogen peroxide solution are enough to disinfect your surfaces. But there's absolutely a catch, like you can't just spray the solution on and wipe it down. You should actually spray down your surfaces, your countertops, and let that solution sit for at least six to eight minutes before you wipe it down. And that's something that the CDC actually recommends. So when you're choosing the type of flooring, you know, in the past, carpeting might have been a warm feel that you were looking for, especially in the waiting room and in offices. And it also helps with acoustics. The carpeted flooring, so down the corridor is something that we've done a lot in the past, but equally important now than ever is the cleanability of your floor. And, you know, in speaking with our flooring manufacturers, porcelain tiles seem to be the most durable when it comes to cleaning with hydrogen peroxide or bleach solutions. And then we've gotten lots of answers from luxury vinyl tiles, which is probably the most common floor in dental offices. And a lot of answers we've been garden. They're a little bit all over the board and different. So we encourage you that before you put those solutions on your floors, do check with your designer who specified your flooring, or check with the manufacturer. But going forward and designing floors throughout, I think I would always recommend a hard surface that you can clean. And.

Even with a soap solution, it does cut down on dirt and grime.

So moving on from flooring to ceilings, probably the most popular ceiling in dental offices are acoustical ceiling tile and grid because they provide excellent acoustical performance and they also give you the access to the mechanicals above. But in some areas, like perhaps in surgical suites, you might want to consider a different type of ceiling. And what comes to mind there is either a vinyl acoustical tile. So it's the same type of product as an acoustical tile, but it is wrapped in a vinyl, which, you know, once in a while you might want to wipe down, or a gypsum board or drywall ceiling, as it gives you a hard surface that can be wiped down periodically. From ceilings, we'll move down to walls. You know, walls can be painted. That's the most economical way there is. Scrubbable paint and wipeable paint. And I'm talking, you know, beyond the eggshell paint you can get at a home improvement store. But there's architectural paints out there that are meant to be scrubbed and cleaned.

Other things and surfaces to consider for wall are vinyl wall coverings, as the name says, you know, it's a vinyl product so it can be wiped down. We like to use those in high traffic areas. And, you know, moving forward, you might want to consider vinyl wall covering in operatories where you can take a soap solution and wipe down your walls. Now, cleaning with soap and water, it removes germs and dirt and.

Impurities come off these surfaces by cleaning and it lowers the risk of spreading infection. Now, the better way to doing things is disinfecting, as it kills the germs in service, of course. And by killing germs on the surface after cleaning, it can further lower the risk of spreading infection. Which brings us to countertops, because I think that's where we use disinfectants the most. So countertops, there's different types of materials you can use on countertops. Quartz is probably the higher end material. It's a man made stone and can be easily cleaned with hydrogen peroxide or bleach solution.

Solid surface is a little bit more softer of a resin material. And then there's of course laminate, which is the most cost effective material you can use when building or purchasing countertops and cabinets with those solid surface and laminates. We've talked to our manufacturers of these materials and we've gotten lots of different cleaning protocols and different feedback from them. So I would really encourage you. Don't just spray down your countertops with a strong solution. Do check with your designer or cabinet installer first of what brand was used and check with the manufacturer to see of what is recommended for cleaning and disinfecting of those countertops and cabinets.

So we've touched a lot on what to look for when building a new practice, I guess. Monica, from here, how do we give patients and staff reassurance going forward?

Yeah, I think we've touched on many points today that when you're planning a new office or what can you do to your existing office post Covid and many of these implementations that we touched on today will actually provide the reassurance, especially the visible ones you touched on Dale.

So you want to promote.

Those implementations to your patients and to your staff and you want to get your business back on track. And so I want to summarize a few of them that we touched on Today. So those were hygiene supplies and hand sanitation station signage on hygiene etiquette and then patient education on monitors and informing them of all the steps you're taking in your office every day. And those physical barriers that we touched on throughout the office and then adjustments to your waiting room like the quantity of chairs and removal of toys and so on. And then having the patient see you're washing your hands or even if you're using hand sanitizer, apply that while you're walking into the operatory and put on fresh gloves right in front of your patients. That is something that gives the patient reassurance and calms them down. And then plan for different protocol on minimal and touchless check in and checkout processes. And then for your staff, you know, individual workstations, you know, share as little equipment as possible, provide PPE for all your staff, not just clinical staff, and provide laundry facilities in the office and.

Or contract a laundry service. So bottom line is, you know, like people are going to feel uncomfortable in, in the beginning and it's not just the patients, it's the staff also. And we need to think about that. We've talked to quite a few of our clients, didn't we? That said, it's not just our patients, it's our staff as well. They might be scared as well. So.

With that I think we can also provide something else that you want to talk about, a software.

You know, I think as the states are opening back up, and I think Gene mentioned at the beginning it was somewhat sudden here in Illinois. I think we got notification on Friday or Saturday and practices started opening on Monday. But there is another way that we haven't touched on yet to help with re engaging your staff, which is to consider soft open of your practice.

You know, we've heard from some doctors about how this reminds them of the AIDS epidemic in the 1980s when they previously did not use gloves when treating patients but subsequently had to implement glove usage. So you need a little time to teach yourself and your team how to treat your patients in the new era of COVID 19, just as Dennis did with previous epidemics. The other thing to consider is extending appointment times to give your staff enough time for changing PPE as well as some cleaning between patients and prepare for the next patient. But above all, communicate and over communicate. You know, communication is key. As they say, reach out to the patients, reach out to the staff. You know, use direct mailing or social media, let the patient know about the steps you've taken not only within as they enter the practice, as we mentioned earlier on. But try that good old fashioned paper letter in their mailbox. Just letting them know what you're doing and what you've done to try to keep them safe. When they come to your practice, keep up the height and communication with staff. What they say is when a staff member receives a handwritten note from their employer or their team leader, that's of all importance to them. So just continue to communicate with your staff verbally and through written communication. Daily huddles and continuing lessons learned within your practice is also very important.

So with all that being said, that concludes our presentation on how we see COVID 19 impacting dental office design going forward. And with that, like to thank everyone for their attention and want to hand it back to you, Jean.

Okay, thank you. Thanks. Dale and Monica. I know there probably are. People are thinking about everything that they could be doing and should be doing. I think, you know, my takeaway is some barriers in between the rooms. And you know, obviously I think there was one comment or question and I think it had to do when you were on the Dale, when you were explaining the H VAC system and kind of just everything pertaining to the.

Filtrations and just a question you had said 300 installations worldwide. And the person said 300 installations worldwide. Almost like that seems like not much. Was it 300 really, or was it more than that?

My apology. 300,000 installations worldwide. And just to touch on the ionization process, that's something that you see a lot in large hospital systems. And we're seeing it and we're recommending it for dental practices now. And you know, again, going back to the filtration, the HEPA filtration, you know, that is being recommended. But I do want to point out again the difference in the size of the molecule. HEPA filters, they catch molecules that are 0.3 micron in size. And the coronavirus by itself is 0.125. And what they're saying is most of the time coronavirus is contained within droplets of water, which is larger. So these HEPA filters do catch it. But that's really why we've narrowed in on the ionization.

So just not that we would hold you to this, but if someone were out there and they're saying in their head like, hey, there were some great ideas today, but I'm not gonna. I'm not building a practice. I have my existing practice. What if you had your brother on the line who was a dentist, and this is a question to either of you, what would you say? Like, hey, this is What I would do. This is like a good reassuring thing and this is about how much it's gonna run you to do what you're going to propose. I'm not saying you are proposing it, I'm not saying you're selling it. I'm just saying like if you had to make a decision today and you were sitting in their seat right now and you weren't doing a build out, you weren't doing a new practice, you were actually had to go back to your practice, what would you recommend they do? Like, what makes sense?

Monica, do you want to start first from physical barriers and.

To your existing practice?

What is easy to do and brings a lot of separation and reassurance is those physical barriers throughout. So having a sneeze guard at the reception desk, that's easy to implement. Same with separation in the waiting area or if you have a bay of ortho or pedo chairs, bringing those physical barriers. And that's something that is simple. But it does help, you know, it does help from, you know, droplets flying through speech and, you know, it's something that's fairly cost effective and can, you know, can be removed, but it doesn't have to in the future, you know, we did.

If I can. Sorry, I'm going to interject a little. So, Monica, are you referring to like when you say a sneep barrier? More like something that would go on top of the reception desk as like a place plexiglass barrier or are you referring, you mentioned earlier, like in an open bay, hanging it from the ceiling to separate the chairs in the open bays. Is that kind of what you're thinking when you're saying that?

Exactly, yep. So you can see those, you can find those on the Internet. You know, you can call somebody local that you have there, but those are exactly what I'm talking about. So any reception desk I would assume would have some sort of a transaction top that could take one of those sneeze guards that you just have freestanding on top of your transaction top. And what that does, it really gives you a physical barrier between the staff member and the patient. So when you're speaking, the droplets are being caught per se, if you are not wearing a mask, perhaps in a month or two, if that is being lifted. So that's the same. Yeah, like you're saying in the bay or in treatment rooms, you know, we've been seeing a lot of open treatment rooms in the last decade. Doctors are looking for some sort of more separation or even aftermarket doors to go over those Openings and those can be all done out of glass or acrylic panels. Okay.

So I also noticed that, you know, in regards to like the barn doors, like that's an outside hanging door. So on some of those operatories that that could be, if they're an existing space that could be maybe incorporated. Is that what you're kind of thinking?

Yeah, absolutely. So, you know, you might, a carpenter, want to come in and add some blocking there to support the weight of a door like this. It would be a little bit more than just hanging something with two screws. But you know, given that you have blocking, or you could add blocking to an existing door, opening a barn door would give you that separation. You know, some of these things are more psychological and others are actual physical barriers. But yeah, anything helps and time will show, you know, what is the best solution here. But there's been a lot of research, I think, on the filtration side of things.

Yeah, go ahead.

No, I was just going to say I just wanted to touch on the physical barriers. And we talked earlier about the travel path of the patient. In practices. It's really difficult to say how can we maintain six feet between patients and staff and other patients. So trying to walk through your practice and say, where am I going to potentially have contact between people? How can I try to avoid that? And where I might have contact, what can I put up temporarily? I thought your illustration was good. If it was my brother that was a dentist looking to do something temporary, what would I recommend?

It goes back to the unknowns that we discussed earlier on in the presentation. I've seen some very temporary solutions out there, such as like medical curtains that can easily be laundried or washed, those getting hung up to try to separate spaces. I've seen some really rudimentary type of exhausting systems set up where it's like a large tarp type material or clear plastic that gets applied indoor openings and then there's an exhausting system to the outdoors. Those kind of systems I think maybe would impact patients perception of the professionalism of the practice. I guess it depends on what sort of image you're trying to portray. My recommendation, like I said earlier, from a ventilation standpoint is just do it right now because I feel very confident that there are going to be long term implications around ventilation. So seeing that there's conversation around the UV lights, around the HEPA filtration, as we mentioned, this ionization system, which we feel is really the proper way of doing it, I would say definitely invest in H Vac right now. In view of coming out ahead and reassuring everyone involved as well.

And this is something you can do post construction, right?

That's right, yeah. So this is not something that's necessarily only allowed for new construction, only available for new construction, or when you put in a new H vac system, this can be retrofitted into the system.

So just again, not holding you to this, but so if that were retrofitted into an existing system, what is the time frame that that would take for a practice to do that? And just, again, just a broad scope, like what would be the low end? What would be the high end of something like that for a practice?

Sure thing, yeah. And cost and timing is an important conversation. As a matter of fact, it's very, very much on our radar right now. There's a lot of doctors that have been trying to get things done quickly while they're closed. So they didn't have any downtime when they opened up. And obviously they were. They would utilize the what we've installed as potential marketing and reassurance for the staff. So from a cost standpoint, on a low end, we've seen as low as $10,000 for retrofitting systems and putting in sneeze guards and temporarily barricading off some areas or blocking, you know, beverage station and drinking fountains. But for larger practices, we've seen it go up to 40, $50,000. And then from a timing perspective, it can be done as quickly as a week, or it could take two or three weeks, you know, for ordering up materials. The installation of the systems doesn't take three weeks. It would take probably about a week. Even in the most extreme situations. But generally speaking, with lead times, my guess is you're probably somewhere between one and three weeks.

A timing standpoint, playing the devil's advocate here. If I were a dentist and I wanted to install an ionization system, should I install it only in the treatment room? So throughout the entire office? Yeah, that's good.

There's been conversation around should we create more of a sterile environment in the back and then have our admin areas non sterile? The challenge is that that works great in hospital settings. You might have or and you go through automatic doors and there's a definite pressure difference. And it's very obvious that it's much more sterile environment.

In a dental office, there are much smaller spaces and I would recommend that you put the system in to control the entire office, not just for individual rooms. Now there are isolation rooms, and I want to be clear about that. If you're looking to create an isolation room within your dental office. Specific isolation rooms, those can have their own standalone systems. But I do overall think that you should look at the entire office and the heating and cooling system for your entire office and how you might be able to protect patients and staff throughout the office.

Okay, great. Well, you answered some great, great questions, gave me some better clarity. I'm sure other people feel the same way.

Any additional questions from anyone that's out there? I'm not seeing anything in chat or anything in the qa. Please feel free. I'm going to pop up the polling. If you can go ahead and answer the polling again. This is just a fun exercise. Maybe you'll be thinking of some questions while you're reading these questions or I'm reading the questions to you. Who are you? Are you a dentist? Associate, hygienist, rda, da office manager, administrator? Are you ready to reopen? Yes or no? Do you feel comfortable with it? Do you have enough PPE protection? Do you feel safe?

True or false? Do you feel prepared to reopen your practice? Do you feel you have proper barriers and protection? Not just PPE related? So keep answering those. Somebody saying thank you for another great lecture. Thanks, Jennifer, we appreciate it. It's people like all of you that come every day or at least a couple of times a week when you're not zoomed out that you are making this much more rewarding. For us, I think for us it's about educating you and helping you to make good decisions in your business and the best care that we can deliver in a patient focused practice.

So.

So thank you for joining us. We're not ready to leave yet. Would negative pressure be advised? Question Would a negative pressure be advised?

Yes. So it goes back to what I mentioned about isolation rooms. Negative pressure is most often seen in isolation rooms. So if you have a specific surgery room, if you're a general dentist and you're gonna be doing any type of surgery, you might create an isolation room that uses negative pressure. But generally speaking, you can't create negative pressure throughout the entire office easily and it does cause strain on the H VAC system. So negative pressure should be more isolated to individual rooms if it's desired.

Okay, good.

Keep feeling comfortable answering more of the questions. The more you answer, the better results we get and we at least get a feel for the audience and what's happening out there. Right now we've got trending dentists online are 56% of the attendees, 11% are associates, 11% are hygienists. Great. I'm glad you're here. 22% are office managers. Great. Glad you're here. Are you ready to open? 56% say they are ready to open. 44% say no, they're not. Have enough PPE and protection? I feel safe. True or false? 56% of you said true. You do feel safe. You feel that you have enough PPE and protection. 50. I'm sorry. 50% of you said true. 50% of you said false. So that's a split. Do you feel prepared to reopen your practice? I have the proper barriers and protection. Not PPE related. 36% of you said yes. 64% of you said no. You do not feel like you have the proper barriers and protection. Not PPE related. So that's interesting.

Now the trend is going up for do you have enough PPE and protection? I feel safe. 55% are saying no, they don't. 45 are saying, yeah, I do. So that switched. It was about even. And are you ready to open that too? Switch. So 45% of you saying yes, 55% of you are saying no, you're not ready to open. So interesting. Very, very interesting. The number of dentists, 64% are on the line. 18% are associates. 9% are hygienists. 18% are office managers. So feel free. There's still a few minutes left. I would love for you to keep answering. We. We've got about a third of you that have answered. Trust me, I don't know who you are. I don't care who you are. I just think it's a great exercise to get some of these stats. I'm going to put them on one big slide and at some point in this week, I'm hoping and share it because I think it's great. I'll probably also put it out there in a marketing piece, not to market you, but just so that you get an idea of what I've got. When I can put all these information questions together, it's so interesting to me to see the trends and then to be able to different, you know, read different news articles or news stations and listen to what's out there in the general public, it kind of helps me to just kind of say, wow, that's interesting. That's kind of how the audience was answering or that isn't what I'm hearing from the dental specific world. So, yeah, anything you can answer is great. Please keep going. We do have another question here and we answered that one about the negative pressure. And then the other thing is from Andreas. Thanks for putting this great information. I wish I would have selected Apex for my build out. Well, that's great.

Next one.

That was really nice. And that's a non paid solicitation.

All right, we're still going, so let me just end the polling. It looks like we're about done here. So again, 64, I think you can. I'm going to share the results with the screen with you. Can you guys all see this?

Yep.

64% were dentists. 55% of you said you're not ready to reopen. 55% of you said you don't have enough PPE and you don't feel safe. And 64% of you said you do not have enough information to feel protected with barriers. So. Hey, Apex, thanks so much. Monica and Dale, I really, really appreciate you taking your time out of your day trying to socially distance as best as you can. You did a great job. I hope you all stay safe and healthy. And again, once again, thank you. Thank you so much. Really, really appreciate it.

Thank you, Jean.

Thank you, Jean. And everyone watching us today, listening to us.

Okay, take care everyone. Bye. See you tomorrow. If you're coming in. Thanks. Bye. Bye.