Episode 785: Building a Scalable Waterline Safety Program for Multi-Location Dental Practices

We tend to put the most responsibility on the person with the least amount of education,
the least amount of pay, and very often the least amount of respect in the office, and that's the
dental assistant. We ask them to do a lot, but we don't give them the time. We don't give them the
training. We don't often give them the pay or the respect that should come with that.
So when things begin to pile up on them... They're not going to drop the things that the dentist is
going to see. Supplies are going to be ordered. Instruments are going to be sterilized. But
waterline maintenance may not happen. Spore testing might not happen.

You're listening to the Dr. Phil Klein Dental Podcast. I'm Dr. Phil Klein, and thanks for joining
us. When we think about infection control and dentistry, we often focus on sterilization, personal
protective equipment, and surface disinfection. But there's another area that's just as important
and sometimes doesn't get the attention it deserves, dental unit water lines.
For DSOs and multi-location practices, maintaining safe, compliant water lines across every office
can be a significant challenge. How do you ensure that protocols are being followed consistently?
How do you create accountability across multiple teams and locations? And how can you simplify
water line management without adding more complexity? to an already busy practice environment.
To help answer those questions, I'm joined by Angela Simmons, founder of Simmons Safe and one of
dentistry's leading experts in compliance and infection control. With more than 35 years of
experience in the dental industry, Angela will share practical strategies for standardizing
waterline protocols, reducing risk, improving compliance, and creating systems that can be
successfully implemented across an entire organization. We'll also take a closer look at silver ion
technology and discuss how it may offer a more effective and scalable approach to maintaining
dental unit waterline safety. So if you're responsible for infection control in a DSO,
group practice, or multi-location organization, this is a conversation you won't want to miss.
Before we bring in our guest, I do want to say what gets me excited about doing this show is that
there are a lot of dental professionals that are enjoying our content, and that makes it all worth
it. And for those that are, be sure to follow us on Apple Podcasts or Spotify, and even better,
leave a review. By doing so, you're not only showing support for what we do here, but your reviews
are instrumental in allowing us to expand our content to dental professionals here in the U.S.
and across the world. So on behalf of our entire team, a heartfelt thank you to all of you. Angela,
it's a pleasure to have you on the show. Dr. Phil, awesome to be here with you as well. Yeah, thank you
very much for your contributions to Viva Learning. You did a great webinar recently that was
released on April 29th, 2026. The silver lining,
simplifying DSO dental unit waterline workflow. And it was very, very well done.
I watched it. And hats off to you for teaching in such a logical and easy way to understand the
major points to this whole thing, which is it's not the water. It's the waterline, which you
emphasized over and over again. Dental unit waterline safety has always been a very important
issue. But now with DSOs and dental practice owners having offices in multiple locations,
which is becoming more and more popular, it can be even more challenging to ensure water safety for
our patients, especially if everyone's not on the same page with waterline protocol. So what are
some of the biggest risks and operational challenges you see when different offices within the same
organization manage their waterlines differently? Waterline safety has always been an issue.
It's just that we didn't recognize it as one until very recently. In the scheme of things,
10 years is not a long time. So even though we had an outbreak in Georgia before the Anaheim
outbreak in 2016, that's the one that kind of blew the lid off of everything.
That's the ground zero for us. So that's one of the biggest issues in my mind is that we've not
been having this conversation for very long. And it takes a while for anything.
I don't care what it is. It takes a while for anything to make its way through an industry,
through organizations, for it to become an acceptable best practice. So I think that's,
for one, that's one of the issues that we have. As an industry, we have started to see more
consolidation and the rise of the DSO. The larger the organization, the bigger the risk.
There's no getting around that. DSOs, just by their very nature,
their risk is going to grow exponentially as the organization itself grows. One of the things that
I see with DSOs is that when they take new practices on,
the management side already has some best practices. They already have a compliance framework that
they likely want to follow, but they're hesitant to make big changes within new within those new
practices or practices that are new to the dso and so part of the message then that unfortunately
gets sent is that whatever we've been doing or not been doing for the last 10 15 20 years is what
we're going to keep doing i was just recently in new york for a dso and i was in one of their
offices and and i think this was An issue there, this dentist had joined the DSO,
and they had some expectations on surrounding compliance and risk management,
but he was very unhappy that I was in his practice. I'm there for them,
and so it was kind of eye-opening for me. I don't take offense.
You can like me or not, it's okay, because I'm there for them. But it was eye-opening that he was
very upset that I was in his practice and I was applying in the facility assessment,
I was applying the DSO's standard. Here's all the areas that we need to evaluate.
And you're either doing it or you're not doing it. And from his perspective, what he had been doing
for 15 or 20 years was what he should be able to keep doing. So I think that is a big risk and a
big concern and something that's hard for them to get their arms around. So it seems logical to me
that in a big organization that owns multiple offices, if each office is doing their own thing
regarding waterline safety, it could lead to all sorts of problems. When you allow organizations,
when you bring these groups together and you allow these individual offices to continue to operate
as they did before, so you have one office that's using iodine and another office that's using
tablets of some form, and then maybe you have another office that's using silver ion, you can't get
your arms around that. There's too many processes. So for them, from a corporate perspective,
when they're going into offices, who's doing what and what are the steps that they're supposed to
follow and when are they supposed to change these products out or add these products in? So it
overcomplicates a process that should be very simple. It seems to me that the DSOs that own a bunch
of these offices should have some centralized portal, some software portal online that allows
individual offices to stay on the same page, document their infection control procedures,
and that kind of thing. I know that's probably not the case. You know, I think one of the things
dentists like about selling to DSOs, number one, they get some money off the table. Number two,
they have some buying power, leveraging the multiple offices, but also they get to maintain their
philosophy of practice. They get to do the dentistry that they were doing all along,
all through their career. When you go in there and evaluate them, for something like waterline
safety protocol, is that a mandate for them to fix what they're currently doing or update what
they're currently doing so that the next time you go back, that's been rectified? Or is that
something more like a suggestion where you are trying to encourage them to do better when it comes
to waterline safety? Yeah, so when I go in to any office, and I've been doing facility assessments
in dental practices for the better part of the last two decades,
really. When I go in, I'm there for the practice or the DSO,
but the practice at the end of the day. My job is to evaluate every area of risk,
front door, back, and that includes water. And to let the office know, what are you doing really,
really well? There's always going to be good things. What are the things that we can maybe do
better on? And what are the things that maybe we're not doing at all that pose the biggest risk? So
that report that I create for them, the assessment that I conduct,
any report, any recommendations is simply for them. There's no regulatory power behind that.
And I always tell people I'm not the enforcer. right i come in i assess i look i give you
recommendations so that hopefully you can make change to avoid the regulatory issues that might
come from non-compliance so um but yes i i think that even with that understanding it's still hard
it's a If you've had a practice for 15 or 20 years and you have somebody coming in and evaluating
what you're doing, I don't care who you are and I don't care how confident you are in yourself.
You're probably going to feel some kind of way about it. Yeah. But I mean, when you get into these
big DSOs or a dentist who owns multiple practices in different locations, there's risk and it's a
big business. There's big money here. And so the dentist. who's doing the clinical work,
who loves his practice, has to understand that he's part of a bigger operation now. And that's the
way it's going to be. Now, do you go back typically after you make that first visit and see if
anything's changed based on your soft recommendations? yeah i just had that just actually having
that conversation with a client right now about that because they they had some issue where i had
been in made some recommendations they had brought the hammer down hey we need to get these things
fixed and and a year rolled around and i went back again and the same issues were present and
probably a few more And so now the stance is on the part of the DSO,
hey, Angela will be back on this day. or Angela will be coming back,
let me know when you're ready. So something that I say a lot about compliance, and this is an issue
for DSOs and even if they have platforms that they're using and some do, or they have SOPs and some
do, some don't, trust but verify. I don't care how good the employee is.
I think that employees want to do the right thing. I think they want to do well.
They want to comply. But sometimes when we look at the busy nature of a dental practice and we look
at how much gets piled onto, and you've probably heard me say this.
I've probably said it in the webinar. We, in this industry,
we tend to put the most responsibility on the person with the least amount of education,
the least amount of pay, and very often the least amount of respect in the office, and that's the
dental assistant. We ask them to do a lot, but we don't give them the time.
We don't give them the training. We don't often give them the pay or the respect that should come
with that. So when things begin to pile up on them, They're not going to drop the things that the
dentist is going to see. Supplies are going to be ordered. Instruments are going to be sterilized.
But waterline maintenance may not happen. Spore testing might not happen.
Some of those things that aren't as obvious to the dentist on a day-to-day basis or when he's
sitting chairside with a patient, some of those things are what's likely to give.
And again, that increases risk. for the dso and one of the things that i see going into offices is
usually if i see a problem in one office it probably exists in the rest of the offices as well very
seldom do i go in and see an isolated problem here and then i go to the next one and there's a
different isolated problem and then i go to another one and it's a different isolated problem i
might see a few variations in issues. And I might see an issue here that I don't necessarily see
anywhere else, but there's usually themes that run through the practices. They're not doing dental
unit waterline maintenance or they're not spore testing, things like that. Now, let me ask you
this. Would it make sense for a DSO type organization to have like an ICC,
infection control coordinator, that kind of jumps around from one office to the other within that
operation? and continually supervises all of the major things that they're concerned about that
could put them at risk, including waterline safety. And another part of that question is, should
each office have somebody held to account, like an ICC, where it's not just delegated to an
assistant, who, as you mentioned, has a lot of other responsibilities? It may not be very visible
to the owner who's paying her salary about how hard she's working to keep up on waterline safety.
That's right. Yeah. So I think, yes, yes, on all counts. There should be somebody in the practice
who is primarily responsible. And I do think that we should be really taking a hard look at the
responsibility that we're putting on individuals. Are we putting too much?
And I'm a kid of the 70s. So I'm not a,
you know, don't work people too hard. That's not my personality. I believe in hard work. That's the
60s. The 60s was that. Yeah. 70s, we worked a little harder, but 60s, we didn't work at all.
So I believe in hard work and honest work and doing the right thing.
But I do believe that we have gotten to a point for whatever the reasons are.
um and this is certainly i love this industry i've been in it for over 30 years so it's certainly
not a knock on anybody it's it's just should we i believe we should evaluate how we are you know
assigning these various tasks and who we're assigning them to if you've got one assistant that is
working share site and then is responsible for sterilization and spore testing and documenting
cycles of sterilization and checking the eyewash station and the AED and the medical emergency kit
and the fire extinguishers and the OSHA manual and the SDS and dental unit waterline safety,
we should probably evaluate if they really, does that assistant have enough time in...
and ordering supplies, do they really have enough time in the day? And I think the likelihood is
that they do not. They don't have enough time in the day to accomplish all of those tasks.
And so, you know, first of all, looking at how we can divide the workload up so that it's more
equitable and can be accomplished. And then making sure,
again, we do such a good job at telling people what to do. and how to do it,
we don't do a great job sometimes at telling people why. You tell me why something is important,
I'm more likely to do it. Yeah, no, it's totally true. And here's how I want you to do it,
but I don't understand the importance behind it, which I think is a major issue with dental unit
waterline safety. We have only been talking about it for 10 years. So as a dental assistant that's
been working in this industry for 20 years or 30 years, Why is the only unit waterline maintenance
so important now? It wasn't important 10 years ago. So I think it's a valid concern and a valid
statement that I hear sometimes from dental assistants in practices.
And I take the time to explain why it's important. And that's why we do these podcasts. That's why
we do webinars, because the only thing that will change what's happening here and the lack of you
know, understanding about how important dental unit waterline maintenance is, the only thing that
will change that is education. Yeah. For those of us who are listening that don't know what
happened in Georgia, can you tell us in a minute or so, because I have more questions I want to ask
you, what was the event that precipitated such national attention to this waterline contamination
story? So there's really three. um instances in georgia um and 2015 was the first one and i think
22 and 24 um don't quote me on those but um anaheim was in the middle right 2016 and for people
that have maybe never heard when you have we have naturally occurring microorganisms in our water I
think most people probably kind of get that on some level. Some of the naturally occurring
microorganisms are the ones that we talk about the most. Legionella is present.
Pseudomonas is present. It's very opportunistic in nature. And then non-tuberculosis
mycobacterium. Abscessus is the one that is most associated with the soft tissue infections.
And in each of these cases, what we what has happened is unfortunately pediatric patients are being
impacted and when we're seeing children who are hospitalized who are having to undergo surgeries iv
antibiotics they're losing permanent teeth they're losing bone structure in their in their head
their face and head they're losing hearing because of the long-term antibiotic use iv antibiotic
use we need to sit up and take notice as an industry and we should not as an industry i see this
too often and i know we do it in our lives as a general rule something will happen in georgia or in
california and we'll look and say Well, I'm in Virginia and it hadn't happened here. So Georgia's a
long ways away. They probably just have bad water there or they just got bad water out in
California. It's a problem everywhere. And again, it's not the water. It is our water lines.
I think that in dental practices, if we have one case, that's too many.
And we should all sit up and take notice. We should all be asking the questions. What can we do to
prevent that? in my office. And it's not enough to say,
and I see this so much with compliance, where something bad happens somewhere and our industry or
any industry will take notice for a couple of minutes. And then we get a little bit of time in
between the event and where we're at currently. And all of a sudden we're like, yeah, I'm not going
to spend the money on that. It's okay. I've never had a problem in my office. So I'm not going to
worry about it. There's no doubt that our foremost priority is to keep the patient safe. And that
is to maintain our water lines and keep it decontaminated. Because these water lines in our dental
units are narrow. They are a perfect scenario for stagnation and biofilm buildup.
And eventually that biofilm breaks down into free-floating bacteria that can be absorbed by the
body. You know, the water coming in is potable by the county, I'm sure. And even the pipes that are
coming into the building where the office is, the water is still acceptable. But once it gets into
the dental unit, because of what I just mentioned, it's a whole different ballgame with the
biofilm. So, you know, we have to be super careful about this for the patients, but it also can
destroy a dental practice because there could be a disgruntled employee that reports poor safety
practices to OSHA. or the Department of Health, or the state dental board.
There's a lot of ways they can do this. Patients can do it if they're even aware, if they have a
problem with the office. So you're leaving yourself vulnerable as a business. Of course, the
patient is number one, but you're also leaving yourself vulnerable as a business. So how can multi
-location dental organizations specifically develop a standardized waterline management strategy
that is practical, that's scalable? And that's easy for every location to follow consistently.
What's the best way to start this project? The first thing that I would say about that is a
standardized protocol is going to be a more affordable protocol. There's just simply no getting
around that. Part of being in a DSO, I think you mentioned this earlier, part of being in a DSO is
being able to leverage that purchasing power. So if one office is using product A and another
office is using product B and yet another office is using product C, you can't leverage purchasing
power. But when you go to a company like SolMedics,
Stericel SolMedics, and you say, we have 40 locations and 290 operatories.
With across those 40 locations, we want to use Stericel. Silver Island technology,
we want to use Steristraw, we want to use Citrusil, and we want to use FastCheck 15. Now we've got
purchasing power, and I actually did just see that in one of my client locations.
They're a DSO with about 40 locations, and they switched their protocol.
They had a... a decent protocol in place um but they they switched their protocol and because they
did because they switched to stericils um sterastrol citricil for their shock and then um fast
check 15 for their testing they brought their pricing down their annual pricing by about forty
thousand dollars And that's huge for an organization. You'd say $40,000, that's maybe money that
goes into training and education or some salaries for those underpaid dental assistants.
Well, no, absolutely. I mean, if you're going to spend the money anyway, you might as well get some
leverage out of it. But it's really important, I think, for a dental office to have support in this
area from the company that's providing these products. Right,
because there's reasons why you shouldn't be. doing certain things with certain pieces of
equipment. And there's always questions to be asked why you're failing the test in one area,
whatever it might be. Has protocol changed? It's nice to have the confidence of a company that does
this for a living that makes these products to advise the office. I mean, they're not going to
charge you for that advice. They're doing it as a customer service. So even if you had five
offices, The fact that if you're getting it from one reputable company, that company is going to
treat you very well because there's five offices at stake. Even if it's their culture to be really
nice and great, when you're representing more business by having more offices buying from the same
company, assuming the product is as good or better than any other company that's in the same
business, it seems to me that makes sense.
the same need among offices owned by the same company, to me, just adds complexity.
Do you agree? Yeah, I agree. So the question that you asked that kind of led to this,
right? How can they standardize their protocols and what's the benefit to that?
So cost. But if you can, you can bring down cost, but then you get your arms around it.
employees have one process that they have to learn right and so i think that that is really really
important it and i see this a lot in dentistry on uh on the whole where i might work in an office
um in the bronx on monday and i'm in yonkers on tuesday and upper you know west side or whatever on
wednesday and you know then back to the bronx on another day and when you standardize those
protocols it's easy for me to step into any one of the offices because it all looks the same so so
there's going to be that east for the employee so you bring down cost on the product itself but
you're also going to bring down costs from uh from an employee perspective right people and
processes it takes me less time to understand get my arms around it to be able to accomplish a task
that no matter which office i go into it's the same process so i already know how to do it i don't
have to try to find you know an sop somewhere i don't have to ask a bunch of questions or try to
guess my way through a process because we're doing the same thing in every single office so that
that cost savings is more than just the the dollars that we see when we sign the check to pay for
the product but it's it's the time commitment right um the the efficiency in in the process the
training yeah i was going to mention i was going to mention training that it really reduces the
cost of training because the the training is all similar because we're all doing the same protocol
and we're all using the same products we all have the same contraindications yes without a doubt
you definitely you definitely want as you said You want a company that's going to provide you
support. And Sterosil has that in spades. I mean, I have to say that in all of the years that I've
been working in compliance, Sterosil does the support really,
really well. I am impressed with that. One of the complaints that I've heard from clients,
whether it's a single location, but especially DSOs, is It doesn't matter what product they're
purchasing. If you, as a company, as a vendor, if you can't help them with the implementation and
the support, then don't even knock on their door. Don't try to sell them a product that you won't
support and that you can't help them implement because that's a lot of products and a lot of
services get sold to DSOs that just die. after the sale.
So you might have this really awesome product that could really benefit the organization in
whatever way, reducing risk. But if it's not implemented, it does nobody any good.
Why would it sit on the shelf and not be implemented? Just because there's a turnover in HR and
people are not familiar with what this is all about. Or maybe they have a better experience with a
different product, so they start ordering something different because they do have support from the
newer company, and then they leave the old stuff on the shelf. So what I see very often is we do a
lot of price comparison in this industry. So even thinking about...
like uh disinfectant wipes so i'll go into an office and i just think about this from an sds
perspective you have to have an sds for all the chemicals so i'll i'll go in and i believe and it's
what i have in policy that they're using cavicide and then i'll go in again and they have bolo
wipes and i'm like what happened to the cavicide well bolo wipes were on sale okay so now we got to
make sure we have the sds but so it's there's there's not this um commitment or this loyalty um to
a product and and if you think about disinfectants nobody's supporting them right we're just
selling these products to them so there's there's no reason for me to feel loyal um if i can get
bolo wipes and i'm i don't know that you can um so i'm not pitching it but so if i can get bolo
wipes you know 10 cents cheaper a canister than i can for capital size and i'm gonna buy that and
so i do think For vendors, if there's vendors listening to this, you need to support your products.
You need to support your clients. And when we think about waterline safety, again,
I think this is what Stericil has in spades. Selling the straws, one-year straw.
Silver ion technology, one of the most stable products on the market, delivers the antimicrobial
very effectively in a very metered way for a year. So they don't have to think about that.
um it's it's a kind of a set it and forget it sell them the citrosyl make sure they understand how
to use the citrus so i know they're doing that um it's compatible with the straw i don't have to
remove the straw six ounces of warm water citrosyl tablets swirl pull it into my lines let it sit
overnight come back and flush it with fresh water the next day and then the fast check 15 making
sure that they have that they have the product They have enough of your product,
and they know how to use your product. And those are the things, that's where you build loyalty,
in my opinion. That's where you're going to build loyalty with the client. Somebody else can come
in and say, you know, I'll sell you this product, 50 cents cheaper. But when you know that,
you know, this vendor is taking care of me, this company is taking care of me, they have helped us
to implement this product. They're making sure that the product's on our shelves. They have
training and education. They have SOPs for us if we don't have them. You can't replace that.
So that company can actually help multi-practice organizations in different locations standardize
their SOP. They can help with standardizing the SOPs. They do have a platform, which I really like.
So the organization can track when they install their straws. They can track their testing of their
water. They can get SOPs, frameworks for SOPs. They can also get training and education.
And that's one of the things that I really like about Sterosyl is the training and education.
Yeah, I mean, that is a very big thing with all the risk involved with the litigious aspect of
this. Because if you get sued and you don't have any... not only documentation of what you've done
on a regular basis for decontaminating your water lines but i'm talking about documentation of
training. That is really, really critical. So before we wrap it up, Angela, I want to ask you, you
prefer silver ion straws over iodine straws.
And you mentioned that in your webinar. Tell us why that is. So I think there's a couple of issues.
And so the first thing I want to say is there's a lot of products out there and they all work on
some level. What I don't like necessarily about iodine is it's not a very stable product.
So it's number one when we look at silver ion technology and iodine.
has longevity it is going to work it is going to meter out that antimicrobial for a year
unfortunately with the iodine right now the way it's designed you can have something called the
teabag effect temperature in the water chemicals in the water solvents in the water can cause the
majority of that chemical to to elute or have that teabag effect where it pushes out of the straw
and so now where you thought you had a six month straw you only have straw that worked for a month
and you have five months where it didn't work and there's no way to look at it and say oh wow we
lost all the iodine in the straw you have that teabag effect and you just don't know it so you know
there's that issue um taste and odor can be a problem iodine just doesn't smell good and it doesn't
taste good with silver ion there's no taste iodine is not equipment friendly it causes oxidization
so you're going to end up or you can end up with corrosion inside of your lines we know that's not
going to happen with the the silver ion and then all those things are bad in my in my mind but
probably one of the bigger concerns that i have from a compliance perspective is the the number of
steps it's not a low maintenance product so employees if if i'm already taxed and we've talked
about this as an employee i've got all these things i have to do every day and then i have to do
dental unit waterline maintenance and you know maybe we're testing and so i've got to you know i'm
going to do my test and hopefully they're going to test before they shock um but i got to do my
test and then i'm going to shock after the test but i have to take the straw out iodine straws have
to come out so that's an extra step i've got to figure out whatever product i'm going to use
because there's no compatibility there um run the shock they'll put a pickup straw on run the shock
go through the whole process there of flushing and then they'll have to put the straw back in so
all of these little steps along the way add time and they add complexity and they add a greater
risk that somebody's going to forget a step. And I've seen it. People have completely forgotten and
God forbid that they're using bleach as their shock. Sadly, please don't use bleach as a shock.
There's no IFU for it. Right. But I've seen that. And if they forget and they run that bleach or
any shock through their straw, they'll completely destroy.
that iodine straw you run citrus sil through the sterosil straw it's compatible so i've reduced my
steps um and i've reduced the complexity of that process and all of that i mean just that's cost
human cost um when you think about that it's really reducing the time so you know it's pretty
tempting to look at two products that are similar and pick the the cheaper one,
because you're going to save money, obviously, or you get it on sale. Number one, the product may
not be as good and you're not going to get the results. Number two, like you mentioned, your HR
costs are going to go up. You're going to end up spending more time servicing that product when
that person who's doing that could be doing something else that's more efficient and more
beneficial to the practice. Yeah, give them an opportunity. When we're looking at a product and
considering buying the cheaper product, think about the amount of time that it takes and give your
employees the best opportunity to comply. Give them the best opportunity to do what's right and
what's necessary. And when we buy a product because it's cheaper, but it has 10 more steps.
then you're already starting at a deficit and already probably a given there that the employee's
not going to have enough time. to comply, to do what's right. And so that may be one of those tasks
that gets dropped. Now we've increased risk again. Yeah. And that employee could be doing something
else that's really valuable for the practice. Very valuable. So that's what it's all about. Angela,
it's been wonderful talking to you. You obviously know so much about this topic. You've been doing
it a while. And Angela is the founder of Simmons Safe. Is there a website where people could get
more information about you? Yep.
Simmonssafe.io. Okay. And Simmons is spelled S-I-M-M-O-N-S, S-A-F-E.io.
Excellent. Well, I hope to have you on again, Angela. And I really hope that the dental community
as a whole realizes the significance. of maintaining their water line, because this is certainly a
very, very important issue for our kiddos, for our older patients, patients that are immune
suppressed and everybody else in between. And we have to be on top of it. We really do, because
that's the best way to do it is through prevention. Thank you so much and have a great evening.
Thanks, Phil.