“The dirtiest area in dental surgery.” www.dentalproducts.net Dental Unit Water “The dirtiest area in dental surgery.” www.dentalproducts.net There are four organizations we are concerned with when discussing DUWL’s: OSHA = Regulatory CDC= Recommendations accepted as standard of care by most dental boards. OSAP = Organization for Safety and Asepsis Procedures ADA = Lobbies for the accepted standards of organized dentistry.

“The Dirtiest Area in Dental Surgery” www.dentalproducts.net Bacterial colonization of dental water lines (DUWLs) was first reported in scientific literature in 1963. Conventional DUWLs expose patients and staff to harmful microorganisms in the office in which you work.

The “Big Four” agree DUWL’s are a problem. These organizations provide the primary opinions on standards of care in Dentistry. All of them have issued many statements regarding DUWL contamination and infection control recommendations.

DUWL Contamination Dynamics Input: Water quality Waterline: Biofilm Output: Retraction and Backflow

Water 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 Backflow Oral microflora have been recovered from DUWL’s. If retraction of patient fluids is not a problem, then why are there anti-retraction valves built into the handpieces??? How do you test a handpiece anti-retraction valve? Eddies of backflow can travel through an open anti-retraction valve even during positive flow!

Waterline Biofilm The small diameter and long length of the DUWL provides a large surface area for the adherence of microorganisms. Microorganisms from water and patients combine in the DUWL and form a biofilm complex similar to dental plaque.

Bacteria in Biofilms Bacteria in biofilms tend to be: -more difficult to culture (for waterline testing) -more resistant to control strategies (antibiotics and biocides) than when grown in the laboratory. Their resilience has been related to physiology and protection by the EPS slime matrix that they produce. Source: http://centerforgenomicsciences.org/research/biofilm.html

Changes in Biofilm Bacteria Changes which occur in microorganisms incorporated in biofilms: Become Chronic in Nature Become Culture Negative Poor Response to Antibiotics Greater Potential for Metastasis http://www.genomenewsnetwork.com /articles/06_02/biofilms.shtml

Sterilization Destroys Biofilms Because of the highly resistant effects of biofilm and its ability to leech endotoxins and microorganisms into dental water even after disinfection, it is critical to sterilize the entire pathway to eliminate the risk of contamination during dental procedures.

Disinfection is not Sterilization Disinfection: Destruction of pathogenic and other kinds of microorganisms by physical or chemical means. * Sterilization: Use of a physical or chemical procedure to destroy all microorganisms including substantial numbers of resistant bacterial spores. *Disinfection does not ensure the degree of safety associated with sterilization processes. Disinfection is less lethal than sterilization, because it destroys the majority of recognized pathogenic microorganisms, but not necessarily all microbial forms (e.g., bacterial spores). Source:CDC Guidelines for Infection Control in Dental Health-Care Settings -2003

Universal Precautions Since disinfection does not = sterility, and dangerous pathogens have been found in DUWL’s, the moment that biofilm contaminated water enters the patient’s mouth, universal precautions are compromised.

Standard of Care Most state Dental Boards consider the 2003 CDC Guidelines for Infection Control in Dental Health Care Settings to be the standard of care in their communities.

compliance in your office? Standard of Care What does that mean for Dental Unit Water compliance in your office?

CDC Guidelines for Infection Control in DUWL’s “Exposing patients or dental health care personnel to water of uncertain microbiological quality, despite the lack of documented adverse health effects, is inconsistent with generally accepted infection control principles.”

“Exposing patients …” any of the following procedures: According to the CDC: you are exposing patients if you perform any of the following procedures: incision, excision, or reflection of tissue… biopsy periodontal surgery apical surgery implant surgery surgical extractions of teeth requiring elevation of mucoperiosteal flap

“…to water of uncertain microbiological quality …” According to the CDC: “Conventional dental units cannot reliably deliver sterile water… …because the water-bearing pathway cannot be reliably sterilized.”

“… despite the lack of documented adverse health effects, …” Since dentistry is typically performed in an outpatient setting, patients are not usually monitored for post-treatment illness. Although this makes it difficult to establish an epidemiologic association between infection and recent exposure to dental unit water, there are several notable exceptions.

“… despite the lack of documented adverse health effects, …” The death of a California dentist from legionellosis. “It is likely that aerosols from those dental units were the source of the fatal Legionella infection." Atlas RM, et al. Appl Environ Microbiol 1995;61:1208-13. Two patients with immunodeficiency infected with Pseudomonas aeruginosa after dental visit. “Identical strain of microorganism identified in the dental unit waterline." Martin MW. Br Dent J 1987;163:152-4. "58 (81.2%) out of 71 patients colonized with Pseudomonas aeruginosa identified in dental unit waterlines. “The microorganism could be identified in the patients 7 days after dental appointment."

“… despite the lack of documented adverse health effects, …” "The temporal onset of asthma may be associated with occupational exposure to contaminated dental unit waterlines”. “Most of the organisms isolated from dental unit waterlines are Gram-negative bacteria, which contain cell wall endotoxin. A consequence of endotoxin exposure is the exacerbation of asthma." Pankhurst, et al. Prim Dent Care. 2005 Apr;12(2):53-9. "Dentists had the highest prevalence of L. pneumophila antibodies, followed by assistants and technicians, when compared with a control group of non-medical workers, indicating that dental personnel are at an increased risk of legionella infection." Reinthaler FF, et al. J Dent Res. 1988 Jun;67(6):942-3.

“… despite the lack of documented adverse health effects, …” OSAP Agrees: “The present lack of epidemiologic evidence of illness or injury among patients or dental healthcare workers does not provide a valid rationale for inaction.”

“… is inconsistent with generally accepted infection control principles.” are based on ensuring no cross contamination and on not introducing new pathogens as a result of the dental procedure. Oral microflora have been recovered from DUWL’s proving cross contamination is possible if not likely.

CDC Recommendations 1. Use water that meets EPA standards. 2. Consult with manufacturer to maintain water quality. 3. Monitoring of water quality 4. Maintenance of the anti-retraction mechanism. 5. Boil water advisories. 6. Eliminate the risk of DHCP non-compliance with disinfectant and water line monitoring.

What can you do? How can you incorporate the recommendations of the CDC into your practice? How can you protect your patients and staff from the dangerous contaminants found in DUWL’s? How can you prevent costly malpractice litigation due to contamination from your practice?

is possible if you choose an STERILE DELIVERY is possible if you choose an unconventional delivery system…

AQUASEPT Sterile Delivery The AQUASEPT sterile delivery system can be retrofitted onto your existing unit to enable you to meet or exceed all of the CDC recommendations for water used in dental procedures.

AQUASEPT CDC Recommendations 1. Use water that meets EPA standards. AQUASEPT lets you use whatever water you want from the sterilized bottle. 2. Consult with manufacturer to maintain water quality. AQUASEPT is sterile every time – no consultation needed. 3. Monitoring of water quality. AQUASEPT allows you to choose the quality of water you are putting in the sterile bottle.

AQUASEPT CDC Recommendations 4. Maintenance of the anti-retraction mechanism. AQUASEPT eliminates reliance on this since the entire pathway is sterilized between each patient. 5. Boil water advisories. AQUASEPT prevents work stoppage, accidental patient exposures and contamination due to boil water advisories. 6. Virtually eliminates the risk of DHCP non-compliance with disinfectant and water line monitoring. AQUASEPT only requires proper sterilization technique- no messy flushing and dangerous chemicals and improper flushing technique.

patients, staff, and practice AQUASEPT DON’T put your patients, staff, and practice at risk!

AQUASEPT peace of mind Choose AQUASEPT and operate with the that sterile delivery brings!

It’s the right thing to do!!! AQUASEPT Sterile Delivery It’s the right thing to do!!!