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OUTLINE 1. Introduction 2. Issues 2.1. Are the potential pathogens from dental unit waterlines a health risk for you as a dental professional? 2.2. What type of patients that might be particularly at risk from contaminated waterlines? 2.3. What can you do to decrease the risk from contaminated waterlines? 2.3.1. Methods for reducing contamination 2.3.2. Latest recommendations regarding dental unit waterlines 3. Discussion 3.1. Method in reducing DUWLs contamination had been practices in Universiti Sains Islam Malaysia (USIM) 4. Recommendation 5. Conclusion 6. References

1. Introduction Effective infection control is one of the cornerstones of good practice and clinical governance. Due to a combination of negative publicity and an increased scientific knowledge of dental unit waterlines (DUWL) biofilms and their associated risks, contamination of dental unit waterlines has become a prominent infection- control issue. The perceived threat to public health from DUWL contamination comes from opportunistic and respiratory pathogens such as Legionella spp (causative agent of the pneumonia, legionnairs disease), Mycobacteria spp and Pseudomonads. These organisms can be amplified in the biofilm to reach infective concentrations, with the potential for inhalation or direct contamination of surgical wounds. (Pankhurst CL et al.) Bacteria in a water line at a dental office in Italy are being blamed for the death of an 82-year-old woman who contracted Legionnaires' disease just days after receiving dental treatment. It occurs on February, 2011, an 82-year-old woman was admitted to the intensive care unit with fever and respiratory distress. She was conscious and responsive. Chest radiograph showed several areas of lung consolidation. She had no underlying disease. Legionnaires disease was promptly diagnosed by Legionella pneumophilia urinary antigen test; a bronchial aspirate was taken for microbiological examination. Oral ciprofloxacin was started immediately. Nevertheless, the patient developed fulminant and irreversible septic shock and died 2 days later. All samples from her home were negative on culture, but those from the dental practice were positive for L. pneumophila. Laboratory experiments demonstrated genomic matching between L. pneumophila found in the patient's respiratory secretion and the dental unit water line. Aerosolized water from high-speed turbine instruments was most likely the source of the infection. (Maria LR et. al., 2012) Biofilm and bacterial contamination of dental unit waterlines (DUWLs) was first reported in the literature nearly 50 years ago. (Blake, 1963) The quality of water from DUWLs is important not only to the patient, but also to dental health care personnel as these groups are regularly exposed to water and aerosols generated from the dental units. (Liaqat and Sabri, 2011) Biofilms are microscopic communities that consist primarily of naturally occurring water bacteria and fungi. They form thin layers on virtually all surfaces, including dental water delivery systems. These common microbes or germs accumulate inside things like showerheads, faucets and fountains, and in the thin tubes used to deliver water in dental treatment. (American Dental Association, 1999) Bioaerosols generated from DUWLs has been shown as a potential source of indirect infection to dental health professionals. (Szymaska and Dutkiewicz, 2008) Most of the bacteria isolated from DUWLs are Gram negative bacteria which can produce endotoxin such as Pseudomonas aeruginosa and Legionnella pneumophilia. Pseudomonas aeruginosa 3

is a natural water-loving biofilm producer, that when aerosolized is almost confirmed to cause pneumonia-like disease in elderly or immuno-compromized individuals. (Atlas et al., 1995, Barbeau et al., 1996) Legionella pneumophilia in the DUWLs is the most frequent cause of human legionellosis as was the case of a dentist in San Francisco, USA, who became seriously ill from the disease. (Atlas et al., 1995) The ADA, OSAP and the CDC have been working since the mid 90s to do research and make recommendations to improve the quality of dental unit water. 2. Issues There are few issues related to the dental unit waterlines, which are: 1. Are the potential pathogens from dental unit waterlines a health risk for you as a dental professional? 2. What type of patients that might be particularly at risk from contaminated waterlines? 3. What can you do to decrease the risk from contaminated waterlines? 2.1. Are the potential pathogens from dental unit waterlines a health risk for you as a dental professional? Bacteria get into our dental system from the original source water. If the water that is used in most dental units comes from the municipal (city) water supply; this is the main source of the microorganisms. The Environmental Protection Agency (EPA) has set a standard that municipal water must contain no more that a total of 500 CFU/ml (colonyforming bacteria per milliliter) A colony-forming unit is defined as one bacterial cell or a small number of bacterial cells and a milliliter are about of a teaspoon. In other words, of a teaspoon of municipal water can have no more than 500 colony forming bacteria. The problem is that even though municipal water enters the dental unit at less than or equal to 500 CFU/ml, the water that exits the dental handpiece or air/water syringe may contain as many as 200,000 cfu/ml. Counts greater than 1,000,000 CFU/ml have been reported (OSAP, 2004). Studies have isolated as many as 32 different bacteria, 6 different types of fungi, and 2 types of protozoa from dental unit water. In addition to municipal water, contamination can also come from the hands of the worker or from retraction of fluids from patients mouths. Sterile water being the only exception to that rule. Most of the bacteria come from retraction. This is why some units have higher contaminations than others. It depends on who was seen in the chair and how badly the unit is retracting. Retraction is the action that occurs when a water relay within the dental unit 4

shuts off and draws water back into the device. It is bad because if the level of retraction is great enough, it will draw bodily fluids back past the handpiece that is being sterilized and into the handpiece hose that is not. 2.2. What type of patients that might be particularly at risk from contaminated waterlines? Some microorganism in DUWLs are harmless and have low pathogenicity, others are opportunistic microbes which can affect individuals who are immunocompromised. Immunocompromised patients are as listed below: Elderly patients Smokers Alcoholic patients Organ transplant patients Recipients of blood transfusions Diabetes Cancer Autoimmune diseases Chronic disorders

If we treat these immunocompromised persons with contaminated water, there is a greater risk that they will become ill due to their compromised ability to fight disease. Since we may not be aware of the immune status of some of our patients, it is especially important to stay current and compliant with the recommendations of the agencies that advise the dental profession. Although we are especially concerned for immunocompromised patients, all patients are entitled to the highest quality of care. This care includes the maintenance of dental unit water. 2.3. What can you do to decrease the risk from contaminated waterlines? The dental unit water becomes stagnant inside the lines at several times; between patients, overnight, on weekends, during lunch breaks. This intermittent stagnation of the water allows the bacteria to grow and flourish on the walls of the waterlines. The four most commonly discussed bacteria within biofilms of Dental Unit Water Line are Legionella pneumophila, Mycobacterium spp., Pseudomonas aeruginosa, and Staphylococcus spp. Basically, there are two types of sources of water of Dental Unit Waterlines, which are municipal water line and reservoir (bottle). Below are the differences of dental unit water line compared to tap water line. 5

Dental unit water line Very small diameter 1/16-1/8 Very slow flow rate drips/sec

Tap water line diameter 5 L/min flow rate (>1000x dental)

Plastic tubing is hydrophobic making Copper as a metal and as a dissociated biofilm attachment easy. The tubing is ion is antimicrobial/bacteriostatic also a source of carbon for the bacteria. Large surface area to volume ratio Rough interior (extrusion molded) Left stagnant for long periods Small surface area to volume ratio Smooth interior Fresh every time turned on

Chlorine rapidly dissipates over 24 Chlorinated and replenished with every hours and can even be absorbed by the use. tubing. Below are the comparisons between distilled water and city water. Distilled Water No Chlorine No Minerals Must be delivered or made onsite Not sterile Chlorinated Calcium, Lime, Rust, etc. Dispensed out of tap Not sterile City Water

2.3.1. Methods for reducing contamination 1. Stop retraction. (Our Clinic Solutions) Install an anti-retraction valve. It only allows the water to flow in one direction. Antiretraction valve can fail as with most leakage problems within a delivery unit, check valves fail due to contamination from biofilm. Once this occurs, the check valve needs to be replaced. 2. Self-Contained Water Systems In order to comply with recommendations, it is necessary to install an independent water supply on each dental unit. This unit can be filled with higher quality (distilled) water than the municipal supply. It also allows for maintenance procedures that lower the overall microbial count. It is impossible to comply with these recommended protocols without a self-contained water supply. Remember that even sterile water in the self-contained bottle will exit the waterline highly contaminated. Therefore, surgical procedures should never be irrigated from a dental unit waterline, but from an independent sterile water delivery system. The use of water heaters in dental units is not recommended because they increase levels of bacterial colonization. The maintenance of the water system is under the control of the doctor and staff. 3. Chemical Treatment Regimens Consult with the manufacturer of the dental unit to determine the proper chemical treatment. Some agents are placed in the bottles once a week, flushed through the lines, and left overnight to decrease the biofilm. Others are added daily to the treatment water to deliver continuous antimicrobial activity in the lines. Chemical agents making antimicrobial claims should be registered with the EPA. There are a lot of methods and chemicals available such as: Dry flushing Bleaching (5.25% sodium hypochlorite 1:10 ratio) Filtration (iodine inline filters, clearline) Sterilization (UV lights) Shock treatments (Mint-A-Kleen, Sterilex) Tablet in bottle treatments (BluTab, ICX) Sterilizable water delivery tubings

4. Microfiltration Cartridges Disposable microfiltration cartridges can be used to decrease dental waterline contamination. They should be inserted as close to the handpiece or air/water syringe as possible. Most are replaced daily. They do not decrease the colonization in the waterline, but filter the microbes before they exit the line into the patients oral cavity. Therefore, filters are often used in combination with antimicrobial agents. 5. Weekly Waterline procedures Remove the self-contained water bottle and empty. Weekly, place the recommended amount of cleaner into the bottle, reconnect, turn unit on to pressurize, and flush line until you see the cleaner coming through the line. Leave for the recommended time period, usually overnight. The next morning, flush all the cleaner through the line. Remove the bottle and fill with high quality water (distilled), flush all the water through the line to remove all the cleaner from the lines. Do not touch the tubing that goes into the bottle. Refill with water.

2.3.2. Latest recommendations regarding dental unit waterlines Guidelines for Properly Treating Dental Unit Waterlines (Updated September 2004). 1) Follow current ADA and CDC recommendations to flush handpiece hoses and air/water syringes for 20-30 seconds between patients. Also, if recommended by the dental unit manufacturer, install and maintain antiretraction valves to prevent oral fluids from being drawn into dental waterlines. 2) Do not heat dental unit water. Warming the water promotes biofilm formation. 3) Consider implementing equipment and procedures that have been shown to improve the quality of water such as separate reservoirs, chemical treatment protocols, and sterile water delivery systems. 4) Use a separate water reservoir system to eliminate the flow of municipal water into the dental unit. This allows better control over the quality of source water for patient care, and eliminates interruptions in dental treatment when local health authorities issue boil-water notices. Contact the manufacturer of the dental unit for recommendations for a compatible system and treatment protocols before purchasing. 5) Use sterile solutions for all surgical irrigations. 6) Educate and train all dental health-care personnel on effective treatment measures to ensure compliance and minimize risks to equipment and personnel. 7) Follow recommendations for monitoring dental unit water quality provided by the manufacturer of the unit or waterline treatment product to assess compliance with recommended protocols and identify technique errors or noncompliance. In the absence of manufacturer's instructions, monitor dental unit water quarterly. 8) Monitor scientific and technological developments to identify improvements as they become available. 9) Ensure that sterile water systems and devices marketed to improve dental water quality have received FDA clearance.

3. Discussion 1. Not every student practices the daily protocol as it is not being highlighted so well. 2. Daily and weekly routine must be done by student with the supervision of supervisor. 3. A written instruction or protocol should be provided as a guidelines or checklist. 3.1.Method in reducing DUWLs contamination had been practices in Universiti Sains Islam Malaysia (USIM) The faculty have strict specification upon buying the dental chair with the technologies to reduce water contamination. Features such as anti-retraction valve must be included. A study had been done by the lecturers of USIM regarding the microbial contamination level of water supply system at the faculty found out that the quality of water supplied at the Faculty of Dentistry, USIM was within the limits recommended by the ADA which is the bacterial loads of not more than 200 cfu/ml for dental procedures. The students before starting their clinical session had being taught by the dental technicians regarding the safety and protocols upon handling the dental chair and its equipments such as the handpieces. Following the protocols by agencies should aids in reducing the contamination of DUWLs such as the recommended protocols by CDC on 2003: 1. Consult with the dental unit manufacturer for appropriate methods and equipment. 2. Follow manufacturers directions for monitoring water quality 3. Discharge water and air for a minimum of 20 to 30 seconds after each patient from any dental device connected to the water system 4. Consult with the manufacturer on the need for periodic maintenance of anti-retraction mechanisms.


4. Recommendation If the students being approach with patient asking regarding the DUWLs, here are some guidelines in explaining the issue of dental unit waterlines to patients in an easy-tounderstand and non-threatening manner. 1) Dental unit waterlines are small tubes (pipes) that deliver water to equipment such as the high-speed handpiece (drill), air/water syringe and ultrasonic scaler [point out these devices in the operatory]. During certain dental procedures, water is used to cool the equipment and to flush away debris. It is also used with ultrasonic instruments to remove calculus (tartar) and stain from teeth. 2) When water is used during a dental procedure, suction is used to vacuum up the water and debris. 3) Microorganisms (germs) that are found in domestic water supplies can contaminate dental unit waterlines. 4) Any surface that is exposed to water for a long period of time can develop a biofilm (organized layer of germs and their products). This problem is common wherever water is delivered through small pipes or tubes, like in the dental units. 5) Microorganisms (germs) found in dental unit waterlines pose a negligible threat to the public and dental team. At present, there are no studies that show increased health risks to dental patients from this water. 6) The bulk of microorganisms (germs) should not cause disease in normal, healthy individuals, but may lead to illness in medical compromised patients (those with a weak body defense system). 7) There are several options to lessen the problem and reduce the risk in dentistry. Some are flushing the waterlines at the beginning/end of the day and between patients, using independent water reservoirs and point-of-use filters, and chemically treating the waterlines. 8) Explain to the patient exactly what your clinic does to address the issue.


Here are also the flow chart to ease the students and the dental assistant as for their daily protocol in reducing the contamination (Ma Mei Siang, 2012): 1) During each day, flush lines 20 to 30 seconds between every patient.

2) In the evening, empty the water from the bottle, places the bottle back on the unit, and flushes all the remaining water out of the lines. Remove the bottle and leave off the unit overnight to dry. The rationale for this procedure is that colonization of microbes is decreased in a dry environment.

3) The next morning, place a clean bottle containing treatment water on the unit and turn on.

4) Flush the line for 2 to 3 minutes prior to seating the first patient. Flushing the line is not considered a water quality control measure. It helps to clear stagnant water from the lines and continues to be recommended at this time.


5. Conclusion DUWL is not a public health concern as it is not wide spread. Therefore, we do not have to explain it to the public unless we are being asked. Contamination of DUWL is universal. It is difficult if not impossible to eradicate the biofilm in these tubing and prevent its regrowth. Nevertheless, every attempt has to be taken to minimize the contamination of the tubing in order to maximize the health of the dental health care personnel and the patient. Although the number of published cases of infection resulting from exposure to water from contaminated DUWLs is limited, there is a medico-legal requirement to comply with potable water standards and to conform to public perceptions on water safety (Sehulster and Chinn, 2003) Dentists are encouraged to follow manufacturers instruction in maintaining the DUWLs and use disinfectant whenever possible. Until ideal guidelines for maintaining DUWLs is released by a professional body, flushing water for 20-30 seconds before starting the morning session and in between patient treatments, remains the most economic way of reducing bacterial load in DUWLs. Most of the microorganisms found in DUWL are Gram negative, heterotrophic bacteria that have little potential to cause disease in immunocompetent people. However, immunocompromised patients and occupational exposed staff members may be at risk of infection by such microorganisms. Owing to the multiple ports of entry of microbes to the DUWL system, at present no single method or device completely eliminates biofilm formation in the waterlines. We must follow the safe water guideline as instructed by the authorities below. CDC (Center of Disease Control & Prevention) - For routine dental treatment, meet regulatory standards for drinking water. <500 CFU/mL of heterotrophic water bacteria. ADA Encourages industry and the research community to improve the design of dental equipment so that by the year 2000, water delivered to patients during nonsurgical dental procedures consistently contains no more than 200 CFU/ml at any point in the time in the unfiltered output of the dental unit. EPA (Environmental Protection & Agency) - The number of bacteria in water used as a coolant/irrigant for nonsurgical dental procedures should be as low as reasonably achievable and, at a minimum, <500 CFU/mL OSAP (Organization for Safety, Asepsis and Prevention) - The regulatory standard for safe drinking water of <500 CFU/mL APHA (American Public Health Association) - the regulatory standard for safe drinking water of <500 CFU/mL 13

AWWA (American Water Works Association) -the regulatory standard for safe drinking water of <500 CFU/mL European Union Drinking Water Standards specify a maximum of 100 CFU/mL Combinations of currently available procedures and equipment, including anti-

retraction devices, flushing, independent water supplies used in conjunction with biocide purges or fully autoclavable waterline circuitry should provide water that is of a standard higher than that of drinking water. However, all these systems require strict adherence to maintenance protocols to perform to their full potential.


6. References 1. American Dental Association (ADA) (1999). Dental unit waterlines:

approaching the year 2000. ADA Council on Scientific Affairs. J Am Dent Assoc, 130(11): 1653-1664. 2. 3. 4. Atlas RM, Williams JF, Huntington MK (1995). Legionella contamination of Adecs Systems Guide, Publication No. 85-0801-00 Barbeau J, Tanguay R, Faucher E, Avezard C, Trudel L, Ct L, Prvost AP dental- unit waters. Appl Environ Microbiol, 61(4): 1208-1213.

(1996). Multiparametric analysis of waterline contamiantion in dental units. Appl Environ Microbiol, 62(11): 3954-3959. 5. 6. 7. 8. 9. Blake GC (1963). The incidence and control of bacterial infection of dental Liaqat I, Sabri AN (2011). Biofilm, dental unit water line and its control. Afr J Martin MV. The significance of the bacterial contamination of dental unit water Ma Mei Siang et. al. The microbiological quality of water from dental unit Maria LR, Stefano F, Federica P, Emanuela F, Maria FP, Paolo F, et. al.. units and ultrasonic scalers. Br Dent J, 115: 413-416. Clin Exper Microbiol, 12(1): 15-21. systems. Br Dent J 1987;163:152-4. waterlines in Malaysian Armed Forces dental centres. Arch Orofac Sci (2012), 7(1): 7. Pneumonia associated with a dental unit waterline. The Lancet. 2012 Feb 18-24, Vol. 379:9816, p. 684. 10. 11. Mills SE. The dental uni t water l ine controversy: defusing the myths, Sehulster L, Chinn RY; CDC; HICPAC (2003). Guidelines for environmental MMWR defining the solutions. J Am Dent Assoc 2000;131:1427-41. infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Recomm Rep, 52(RR-10): 1-42. 12. Szymaska J, Dutkiewicz J (2008). Concentration and species composition of aerobic and facultatively anaerobic bacteria released to the air of a dental operation area before and after disinfection of dental unit waterlines. Ann Agric Environ Med, 15(2): 301-307. 13. & 14. Julian Holmes. Dental Unit Water Lines (DUWLs) A Review of The Problem Solutions. Retrieved


http://www.the-o- on 1 April 2012. Pankhurstn CL, Johnson NW, Woods RG. Microbial contamination of dental 15 unit waterlines: the scientific argument. Int Dent J 1998;48:359-68


USAF Dental Evaluation & Consultation Service. Retrieved from on 1st April 2012. 16. Caroline LP. Risk Assessment of Dental Unit Waterline Contamination. Retrieved from on 1st April 2012. 17. OSAP. Retrieved from on 1st April 2012.