Dental Unit WaterDental Unit Water

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

www.dentalproducts.netwww.dentalproducts.net

““The Dirtiest Area in Dental The Dirtiest Area in Dental Surgery”Surgery”www.dentalproducts.netwww.dentalproducts.net

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

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

The “Big Four” agree DUWL’s The “Big Four” agree DUWL’s are a problem.are 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 If retraction of patient fluids is not a problem, thenproblem, then why are there anti-why are there anti-retraction valves built into the retraction valves built into the handpieceshandpieces??????

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

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

Waterline BiofilmWaterline Biofilm

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

MicroorganismsMicroorganisms from water and patients from water and patients combine in the DUWL and form a combine in the DUWL and form a biofilm biofilm complexcomplex 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 (for waterline testing)testing)

--more resistant to control more resistant to control strategiesstrategies (antibiotics and biocides) (antibiotics and biocides)

than when grown in the than when grown in the laboratorylaboratory. .

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

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

Changes in Biofilm Changes in Biofilm BacteriaBacteria

Become Become ChronicChronic in Nature in Nature

Become Become Culture NegativeCulture Negative

Poor Response to Poor Response to AntibioticsAntibiotics

Greater Greater Potential for Potential for MetastasisMetastasis http://http://

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

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

Sterilization Destroys Sterilization Destroys BiofilmsBiofilms

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

endotoxinsendotoxins and and

microorganismsmicroorganisms into dental into dental waterwater even after even after disinfectiondisinfection, ,

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

Disinfection is not Disinfection is not SterilizationSterilization

Disinfection:Disinfection: Destruction of pathogenic and other kinds of Destruction of pathogenic and other kinds of microorganisms by physical or chemical means. *microorganisms by 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 substantial numbers of resistant bacterial spores.bacterial 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 than sterilization, because it destroys the majority of recognized pathogenic microorganisms, but not necessarily recognized pathogenic microorganisms, but not necessarily allall microbial forms (e.g., microbial forms (e.g., bacterial spores).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 patient’s

mouthmouth, ,

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 in Dental Health Care SettingsSettings

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 What does that mean forfor

Dental Unit Water Dental Unit Water compliance in compliance in youryour

officeoffice??

CDC Guidelines for CDC Guidelines for Infection Control in Infection Control in

DUWL’s 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 generally acceptedaccepted 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 surgical extractions of teeth requiring elevation of mucoperiosteal flap 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 sterile water… reliably deliver sterile water…

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

cannot be cannot be reliably reliably sterilizedsterilized.” .”

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

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

Although this makes it Although this makes it difficultdifficult to establish an epidemiologic to establish an epidemiologic association between infection association between infection and recent exposure to dental and recent exposure to dental unit water, there are several unit water, there 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 It is likely that aerosols from those dental

units were the source units were the source of the fatal Legionella of the fatal Legionella infection."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 Two patients with immunodeficiency infected with Pseudomonas aeruginosa after dental visit.Pseudomonas aeruginosa after dental visit.

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

Martin MW. Br Dent J 1987;163:152-Martin MW. Br Dent J 1987;163:152-4.4.

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

Martin MW. Br Dent J 1987;163:152-Martin MW. Br Dent J 1987;163:152-4.4.

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

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

““Most of the organisms isolated from dental unit Most of the organisms isolated from dental unit waterlines are waterlines are Gram-negative bacteria, which Gram-negative bacteria, which contain cell wall endotoxin. A contain cell wall endotoxin. A consequence of consequence of endotoxin exposure is the exacerbation of endotoxin exposure is the exacerbation of asthma." asthma."

Pankhurst, et al. Prim Dent Care. 2005 Pankhurst, et al. Prim Dent Care. 2005 Apr;12(2):53-9.Apr;12(2):53-9.

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

Reinthaler FF, et al. J Dent Res. 1988 Reinthaler FF, et al. J Dent Res. 1988 Jun;67(6):942-3.Jun;67(6):942-3.

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

OSAP Agrees:OSAP Agrees:

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

“… “… is inconsistentinconsistent with generally accepted generally accepted infection

control principles.”

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

contaminationcontamination and on not and on not

introducing introducing new pathogensnew pathogens as a result of the dental as a result of the dental

procedure.procedure.

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

proving proving cross contaminationcross contamination is is possible possible if not likelyif not likely. .

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

What can you do?What can you do?

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

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

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

STERILE DELIVERYSTERILE DELIVERY

isis possible if you choose possible if you choose anan

unconventionalunconventional delivery delivery system…system…

AQUASEPT AQUASEPT Sterile DeliverySterile Delivery

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

existing unit to enable you to existing unit to enable you to meet or exceedmeet or exceed all of all of the 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 lets you use whatever water you want from the sterilized bottle.from the 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 is sterile every time – no consultation needed.needed.

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

AQUASEPTAQUASEPT allows you to choose the quality of allows you to choose the quality of water you are putting in the sterile bottle.water you 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 eliminates reliance on this since the entire pathway is sterilized between each patient.entire 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 6. Virtually eliminates the risk of DHCP non-compliance with disinfectant and water line monitoring.disinfectant and water line monitoring.

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