Dental Unit WaterDental Unit Water

““The dirtiest area in dental The dirtiest area in dental surgery.”surgery.”

www.dentalproducts.netwww.dentalproducts.net

““The Dirtiest Area in Dental The Dirtiest Area in Dental Surgery”Surgery”

www.dentalproducts.netwww.dentalproducts.net

Bacterial colonizationBacterial colonization of dental water lines of dental water lines (DUWLs) was first (DUWLs) was first reported in scientific reported in scientific literature in 1963.literature in 1963.

Conventional DUWLsConventional DUWLs expose patients expose patients and staffand staff to harmful to harmful microorganisms in the microorganisms in the office in which you office in which you work. work.

The “Big Four” agree DUWL’s are The “Big Four” agree DUWL’s are a problem.a problem.

These organizations provide the primary opinions These organizations provide the primary opinions

on standards of care in Dentistry.on standards of care in Dentistry.

All of them have issued many statements regarding DUWL All of them have issued many statements regarding DUWL contamination and infection control recommendations.contamination and infection control recommendations.

DUWL Contamination DUWL Contamination DynamicsDynamics

Input: Water qualityInput: Water quality

Waterline: BiofilmWaterline: Biofilm

Output: Output: Retraction and BackflowRetraction and Backflow

Water QualityWater Quality

Tap water is a reliable source of contamination.

You have no way of knowing exactly what is in it at any given time.

Distilled or sterile water is not good enough unless the reservoir and the DUWL are sterile.

Retraction and BackflowRetraction and Backflow

Oral microfloraOral microflora have been recovered from have been recovered from DUWL’s.DUWL’s.

If retraction of patient fluids is not a problem, thenIf retraction of patient fluids is not a problem, then why are there anti-retraction valves built why are there anti-retraction valves built into the handpiecesinto the handpieces??????

HowHow do do youyou test a handpiece anti-retraction valve test a handpiece anti-retraction valve??

Eddies of backflowEddies of backflow can travel through an open can travel through an open anti-retraction valveanti-retraction valve even during positive even during positive flow!flow!

Waterline BiofilmWaterline Biofilm

The small The small diameterdiameter and long and long lengthlength of the DUWL of the DUWL provides a provides a large surface arealarge surface area for the for the adherence of adherence of microorganismsmicroorganisms..

MicroorganismsMicroorganisms from water and patients combine in from water and patients combine in the DUWL and form a the DUWL and form a biofilm complexbiofilm complex similar to similar to dental plaquedental plaque..

Bacteria in BiofilmsBacteria in Biofilms

Bacteria in biofilmsBacteria in biofilms tend to be:tend to be:

--more difficult to culturemore difficult to culture

(for waterline testing)(for waterline testing)

--more resistant to control strategiesmore resistant to control strategies (antibiotics (antibiotics

and biocides) and biocides)

than when grown in the laboratorythan when grown in the laboratory. .

Their resilience has been related to Their resilience has been related to physiology and protection by the physiology and protection by the EPS EPS slime matrixslime matrix that they produce. that they produce.

Source: http://centerforgenomicsciences.org/research/biofilm.htmlSource: http://centerforgenomicsciences.org/research/biofilm.html

Changes in Biofilm BacteriaChanges in Biofilm Bacteria

Become Become ChronicChronic in Nature in Nature

Become Become Culture NegativeCulture Negative

Poor Response to AntibioticsPoor Response to Antibiotics

Greater Greater Potential for MetastasisPotential for Metastasis

http://http://www.genomenewsnetwork.com www.genomenewsnetwork.com /articles/06_02/biofilms.shtml/articles/06_02/biofilms.shtml

Changes which occur in microorganisms incorporated in Changes which occur in microorganisms incorporated in biofilms:biofilms:

Sterilization Destroys Sterilization Destroys BiofilmsBiofilms

Because of the highly resistant effects Because of the highly resistant effects of of biofilm biofilm and its ability to leech and its ability to leech

endotoxinsendotoxins and and

microorganismsmicroorganisms into dental into dental waterwater even after disinfectioneven after disinfection, ,

it isit is critical to critical to sterilize the sterilize the entire pathwayentire pathway to eliminate to eliminate the risk of contamination during the risk of contamination during dental procedures.dental procedures.

Disinfection Disinfection is notis not SterilizationSterilization

Disinfection:Disinfection: Destruction of pathogenic and other kinds of microorganisms by Destruction of pathogenic and other kinds of microorganisms by physical or chemical means. *physical or chemical means. *

Sterilization:Sterilization: Use of a physical or chemical procedure to destroyUse of a physical or chemical procedure to destroy all all microorganismsmicroorganisms including including substantial numbers of resistant bacterial substantial numbers of resistant bacterial spores.spores.

*Disinfection *Disinfection does notdoes not ensure the degree of safety ensure the degree of safety associated with sterilization associated with sterilization

processes.processes.

Disinfection is Disinfection is less lethalless lethal than sterilization, because it destroys the majority of recognized than sterilization, because it destroys the majority of recognized pathogenic microorganisms, but not necessarily pathogenic microorganisms, but not necessarily allall microbial forms (e.g., bacterial spores). microbial forms (e.g., bacterial spores).

Source:CDC Guidelines for Infection Control in Dental Health-Care Settings -2003Source:CDC Guidelines for Infection Control in Dental Health-Care Settings -2003

Universal PrecautionsUniversal Precautions

SinceSince disinfection disinfection does does notnot = = sterilitysterility,,

and and dangerous pathogensdangerous pathogens have been found in DUWL’s, have been found in DUWL’s,

the moment thatthe moment that biofilm contaminatedbiofilm contaminated water enters thewater enters the patient’s mouthpatient’s mouth, ,

universal precautionsuniversal precautions are are compromised.compromised.

Standard of CareStandard of Care

Most Most state Dental Boardsstate Dental Boards consider theconsider the

2003 2003 CDC Guidelines for CDC Guidelines for Infection Control Infection Control

in Dental Health Care Settingsin Dental Health Care Settings

to be theto be the standard of carestandard of care in their communities.in their communities.

Standard of CareStandard of Care

What does that mean forWhat does that mean for Dental Unit Water Dental Unit Water compliance in compliance in youryour

officeoffice??

CDC Guidelines for Infection CDC Guidelines for Infection Control in DUWL’s Control in DUWL’s

““ExposingExposing patients or dental health care personnel to

water of uncertainuncertain microbiological quality,

despitedespite the lack of documented adverse

health effects,

is inconsistentinconsistent with generally acceptedgenerally accepted

infection control principles.”

““ExposingExposing patients …”

According to the CDC:According to the CDC:

you are you are exposing patientsexposing patients if you perform if you perform anyany of the following procedures:of the following procedures:

incision, excision, or reflection of tissue…incision, excision, or reflection of tissue…

biopsybiopsy

periodontal surgeryperiodontal surgery

apical surgeryapical surgery

implant surgeryimplant surgery

surgical extractions of teeth requiring elevation of mucoperiosteal flap surgical extractions of teeth requiring elevation of mucoperiosteal flap

“…“…to water of uncertain to water of uncertain microbiological qualitymicrobiological quality …”

According to the CDC: According to the CDC:

““ConventionalConventional dental units dental units cannotcannot reliably deliver reliably deliver sterile water… sterile water…

……because the because the water-bearing pathway water-bearing pathway

cannot be cannot be reliably sterilizedreliably sterilized.” .”

“… “… despitedespite the lack of documented adverse health effects, …”

Since dentistry is typically performed in Since dentistry is typically performed in an an outpatient settingoutpatient setting, patients are not , patients are not usually monitored for post-treatment usually monitored for post-treatment illness. illness.

Although this makes it Although this makes it difficultdifficult to to establish an epidemiologic association establish an epidemiologic association between infection and recent between infection and recent exposure to dental unit water, there exposure to dental unit water, there are several are several notable exceptionsnotable exceptions. .

“… “… despitedespite the lack of documented adverse health effects, …”

The death of a California dentist from legionellosis.The death of a California dentist from legionellosis. ““It is likely that aerosols from those dental units were the It is likely that aerosols from those dental units were the

source source of the fatal Legionella infection."of the fatal Legionella infection." Atlas RM, et al. Appl Environ Microbiol Atlas RM, et al. Appl Environ Microbiol

1995;61:1208-13.1995;61:1208-13.

Two patients with immunodeficiency infected with Pseudomonas Two patients with immunodeficiency infected with Pseudomonas aeruginosa after dental visit.aeruginosa after dental visit.

““Identical strain of microorganism identified in the dental unit Identical strain of microorganism identified in the dental unit waterline." waterline."

Martin MW. Br Dent J 1987;163:152-4.Martin MW. Br Dent J 1987;163:152-4.

"58 (81.2%) out of 71 patients colonized with Pseudomonas "58 (81.2%) out of 71 patients colonized with Pseudomonas aeruginosa identified in dental unit waterlines.aeruginosa identified in dental unit waterlines.

““The microorganism could be identified in the patients 7 days The microorganism could be identified in the patients 7 days after after dental appointment." dental appointment."

Martin MW. Br Dent J 1987;163:152-4.Martin MW. Br Dent J 1987;163:152-4.

“… “… despitedespite the lack of documented adverse health effects, …”

"The temporal onset of asthma may be associated with occupational "The temporal onset of asthma may be associated with occupational exposure to contaminated dental unit waterlines”.exposure to contaminated dental unit waterlines”.

““Most of the organisms isolated from dental unit waterlines are Most of the organisms isolated from dental unit waterlines are Gram-negative bacteria, which contain cell wall Gram-negative bacteria, which contain cell wall

endotoxin. A endotoxin. A consequence of endotoxin exposure is the consequence of endotoxin exposure is the exacerbation of exacerbation of asthma." asthma."

Pankhurst, et al. Prim Dent Care. 2005 Apr;12(2):53-Pankhurst, et al. Prim Dent Care. 2005 Apr;12(2):53-9.9.

"Dentists had the highest prevalence of L. pneumophila antibodies"Dentists had the highest prevalence of L. pneumophila antibodies,, followed by assistants and technicians, when compared with a control followed by assistants and technicians, when compared with a control group of non-medical workers, group of non-medical workers, indicating that dental personnel are at indicating that dental personnel are at an increased risk of legionella infection."an increased risk of legionella infection."

Reinthaler FF, et al. J Dent Res. 1988 Jun;67(6):942-Reinthaler FF, et al. J Dent Res. 1988 Jun;67(6):942-3.3.

“… “… despitedespite the lack of documented adverse health effects, …”

OSAP Agrees:OSAP Agrees:

““The present lack of epidemiologic evidence The present lack of epidemiologic evidence of illness or injury among patients or of illness or injury among patients or dental healthcare workers dental healthcare workers does notdoes not provide a valid rationale for inaction.”provide a valid rationale for inaction.”

“… “… is inconsistentinconsistent with generally generally accepted accepted infection control principles.”

Generally acceptedGenerally accepted infection control principles infection control principles are based on ensuring are based on ensuring no cross contaminationno cross contamination

and on not introducing and on not introducing new new pathogenspathogens

as a result of the dental procedure.as a result of the dental procedure.

Oral microfloraOral microflora have been recovered from DUWL’s have been recovered from DUWL’s

proving proving cross contaminationcross contamination is is possible if not possible if not likelylikely. .

CDC RecommendationsCDC Recommendations

1. Use water that meets EPA standards. 1. Use water that meets EPA standards.

2. Consult with manufacturer to maintain water quality. 2. Consult with manufacturer to maintain water quality.

3. Monitoring of water quality3. Monitoring of water quality

4. Maintenance of the anti-retraction mechanism. 4. Maintenance of the anti-retraction mechanism.

5. Boil water advisories. 5. Boil water advisories.

6. Eliminate the risk of DHCP non-compliance with disinfectant and water line 6. Eliminate the risk of DHCP non-compliance with disinfectant and water line monitoring.monitoring.

What can you do?What can you do?

How can How can youyou incorporate the incorporate the recommendations of the CDC into recommendations of the CDC into your practice?your practice?

How can How can youyou protect your protect your patients and staff from the patients and staff from the dangerous contaminants found in dangerous contaminants found in DUWL’s?DUWL’s?

How can How can youyou prevent costly prevent costly malpractice litigation due to malpractice litigation due to contamination from your contamination from your practice?practice?

STERILE DELIVERYSTERILE DELIVERY

isis possible if you choose an possible if you choose an

unconventionalunconventional delivery delivery system…system…

AQUASEPT AQUASEPT Sterile DeliverySterile Delivery

The The AQUASEPTAQUASEPT sterile delivery system can be retrofitted onto sterile delivery system can be retrofitted onto your your

existing unit to enable you to existing unit to enable you to meet or exceedmeet or exceed all of the all of the CDC CDC

recommendationsrecommendations for water used in dental procedures. for water used in dental procedures.

AQUASEPTAQUASEPTCDC RecommendationsCDC Recommendations

1. Use water that meets EPA standards. 1. Use water that meets EPA standards.

AQUASEPTAQUASEPT lets you use whatever water you want from the lets you use whatever water you want from the sterilized bottle.sterilized bottle.

2. Consult with manufacturer to maintain water quality. 2. Consult with manufacturer to maintain water quality.

AQUASEPTAQUASEPT is sterile every time – no consultation needed. is sterile every time – no consultation needed.

3. Monitoring of water quality. 3. Monitoring of water quality.

AQUASEPTAQUASEPT allows you to choose the quality of water you allows you to choose the quality of water you are putting in the sterile bottle.are putting in the sterile bottle.

AQUASEPTAQUASEPT CDC Recommendations CDC Recommendations

4. Maintenance of the anti-retraction mechanism. 4. Maintenance of the anti-retraction mechanism.

AQUASEPT AQUASEPT eliminates reliance on this since the entire eliminates reliance on this since the entire pathway is sterilized between each patient.pathway is sterilized between each patient.

5. Boil water advisories. 5. Boil water advisories.

AQUASEPT AQUASEPT prevents work stoppage, accidental patient prevents work stoppage, accidental patient exposures and contamination due to boil water advisories.exposures and contamination due to boil water advisories.

6. Virtually eliminates the risk of DHCP non-compliance with disinfectant 6. Virtually eliminates the risk of DHCP non-compliance with disinfectant and water line monitoring.and water line monitoring.

AQUASEPT AQUASEPT only requires proper sterilization technique- no only requires proper sterilization technique- no messy flushing and dangerous chemicals and improper flushing messy flushing and dangerous chemicals and improper flushing technique. technique.

AQUASEPTAQUASEPT

DON’TDON’T put yourput your

patients, staff, and practicepatients, staff, and practice

at risk!at risk!

AQUASEPTAQUASEPT

Choose Choose AQUASEPT AQUASEPT and operate with the and operate with the

peace of mindpeace of mind that that sterile deliverysterile delivery brings! brings!

AQUASEPTAQUASEPT

Sterile Delivery Sterile Delivery

It’s the right thing to do!!!It’s the right thing to do!!!