1. Waterlines: Science & FCDH Procedures By: Arye, Yishen, Alexandra, and Pamela

2. What’s Important About DUWLs 1/16 th to 1/8 th inch in diameter 1/16 th to 1/8 th inch in diameter Large surface to volume ratio (low flow rate) Large surface to volume ratio (low flow rate) Delivers water to handpieces and air/water syringes Delivers water to handpieces and air/water syringes Water sits stagnant in lines overnight and weekends Water sits stagnant in lines overnight and weekends Optimal breeding ground for microorganisms Optimal breeding ground for microorganisms Plastic hydrophobic surface Plastic hydrophobic surface http://us.a- dec.com/~/media/Adec/Page%20Hero%20I mages/Products/DeliverySystems/A- dec500/Traditional/500Traditional-Hand.jpg

3. What You Need to Know About Biofilms Well organized microbial communities that adhere to wet surfaces Well organized microbial communities that adhere to wet surfaces Communicates via fluid channels to support bacterial growth Communicates via fluid channels to support bacterial growth Protective slime layer which makes it difficult to eradicate Protective slime layer which makes it difficult to eradicate

4. Organisms Present in DUWLs Streptococcus mitis Streptococcus salivarius Enterococci Staphylococcus cohnii Staphylococcus warneri A Klebsiella (Enterobacter) aerogenes Bacillus subtilis Pseudomonas spp. Streptococcus (Entercoccus) faecalis Enterobacter cloacae Pseudomonas aeruginosa Alcaligenes faecalis Mycobacterium spp. Cladosporium spp. Cephalosporium spp. Aeromonas spp. Legionella pneumophila Acinetobacter spp. Flavobacterium spp. Moraxella spp. Ralstonia pickettii

5. Pathogenicity Most Gram-negative species in DUWLs are generally non- pathogenic Potentially pathogenic microorganisms: Pseudomonas aeruginosa- causes oral infections Legionella pneumophila- causes pneumonia Few cases of cross- infections linked to DUWLs http://www.dentalindia.com/wlbf.jpg

6. Pathogenicity Cont’d Chemo patient with Pseudomonas aeruginosa infection Patient infected with Legionella pneumophila http://www.intechopen.com/source/ht ml/46278/media/fig4.png http://jmm.sgmjournals.org/content/59/10/1 242/F1.large.jpg

7. Incidence of Legionnaire’s Disease In 2012, ABC News reported that an 82-year- old woman dies of Legionnaire’s disease after dental visit.

8. Sources of Contamination Municipal water piped into dental unit Municipal water piped into dental unit Suck-back of saliva into line Suck-back of saliva into line Lack of antiretraction valves Lack of antiretraction valves Contamination from independent bottled water systems Contamination from independent bottled water systems 300 times more amoebae found in DUWLs than in tap water 300 times more amoebae found in DUWLs than in tap water

9. Laws for Decontamination of DUWLs There are currently no laws that set standards for the quality of water There are currently no laws that set standards for the quality of water 1995- ADA challenged industries to produce systems that reduce bacteria levels 1995- ADA challenged industries to produce systems that reduce bacteria levels Cleaner than tap water (500 CFU/ml) Cleaner than tap water (500 CFU/ml) http://www.thenextdds.com/uploadedImage s/The_Next_DDS/Articles/3338650.jpg

10. CDC Recommendations Flush water lines for: Flush water lines for: 30 seconds at beginning and end of day 30 seconds at beginning and end of day 20-30 seconds after each patient 20-30 seconds after each patient Do not use dental unit water for surgical procedures Do not use dental unit water for surgical procedures http://www.ada.org/en/member-center/oral-health-topics/dental-unit-waterlines

11. ADA Recommendations Improve the design of new dental equipment Improve the design of new dental equipment Design accessories to adapt to older units Design accessories to adapt to older units Take responsibility off HCW Take responsibility off HCW http://www.l wtech.edu/i mages/Ace damics/Den tal/Dental_ Assistant.jp g

12. Goals for Disinfection Practice Minimize and prevent biofilm formations Minimize and prevent biofilm formations Improve the safety and quality of dental unit water Improve the safety and quality of dental unit water Remove bacteria from tubing surface Remove bacteria from tubing surface Decrease potential source of cross contaminations Decrease potential source of cross contaminations Easy procedures that can be performed daily Easy procedures that can be performed daily http://trustwater.com/wp- content/uploads/2012/02/teeth.jpg

13. Quality Improvement Methods Autoclavable or disposable pathways Flushing waterlines Filtration system Independent reservoirs Sterile water delivery system Chemical treatment Chlorination Biocides and chemical disinfectants Peroxide, Ozone UV

14. http://www.dentalaegis.com/m edia/20301 http://vertassets.blob.core.windows.net/i mage/1a88ed98/1a88ed98-2e3f-11d3- 9a4b-00a0c9c83afb/aquasafe.jpg http://www.aquasept.com/wp- content/uploads/2012/04/cass ette.jpg http://www.waterclave.com/I mages/waterclave6.jpg The Waterclave

15. FCDH Procedure Remove handpieces, air/water syringes, and ultrasonic scalers Flush lines: Beginning of day for 60 seconds Between patients for 20-30 seconds At end of day for 60 seconds

16. Why do we run the waterlines? May temporarily reduce the level of microbes in the waterlines Reduces patient-borne microbes that may have entered the handpiece via suck-back Reduces the build up of biofilms in the DUWLs Inexpensive and easy to do

17. The Pink Stuff- Purevac On Fridays: Fill bucket with 2 pumps Purevac and water (1 ounce/1 quart) Suction with low and high-speed suction http://www.net32.com/images/evacuati on/sultan-purevac-21113.jpg A powerful cleaning solution that: Destroys microorganisms Dissolves tough debris Keeps evacuation lines open Prevents build-up Helps system operate properly and efficiently

18. The BluTab Inhibits growth of microorganisms in DUWLs Nontoxic, odorless, tasteless Has no effect on enamel or bonding https://www.safcodental.com/catalog/infection- control/waterline-purification/blutab Add 10 BluTabs to 19 liters of water (1 tablet / 2 liters H2O) Fill individual dental unit water bottles with treated solution

19. References 1.ADA: America’s leading advocate for oral health [Internet].Chicago: American Dental Association; C 1859- 2014. Oral Health Topic Dental Unit Waterlines; April 2012 [cited 2014 November 1]. Available from: http://www.ada.org/en/member-center/oral-health-topics/dental-unit-waterlines 2.Bednarsh HS, Eklund KJ, Mills S. OSAP- Dental Unit Waterlines: Check Your Dental Unit Water IQ [Internet]. American Dental Hygienists’ Association; 1997 [cited 2014 Nov 18];10(9). Available from: http://www.osap.org/?page=Issues_DUWL_7 3.BluTab [Internet]. Safco Dental Supply; 2014 [cited 2014 Nov 19]. Available from: https://www.safcodental.com/catalog/infection-control/waterline-purification/blutab 4.Dallolio L, Scuderi A, Rini M, Valente S, Farruggia P, Sabattini M, Pasquinelli G, Acacci A, Roncarati G, Leoni E. Effect of different disinfection protocols on microbial and biofilm contamination of dental unit waterlines in community dental practices. Environ Res Public Health [Internet]. 2014 Feb 18 [cited 2014 Nov 18]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3945585/ 5.Garg SK, Mittal S, Kaur P. Dental unit waterline management: historical perspectives and current trends. J Investig Clin Dent [Internet]. 2012 Feb 19 [cited 2014 Nov 18];3(4):247-52. 1.Purevac Evacuation System Cleaner [Internet]. Sultan Healthcare; 2014 [cited 2014 Nov 19]. Available from: http://www.sultanhc.com/sw/swchannel/productcatalogcf_v2/internet/model.asp?ProductMasterID=297561&P arentID=215652&SWID=1 2.Tyagi S, Kulkarni P, Prasad K. Science regarding dental unit waterlines (DUWL): A review. Ann Essences Dent [Internet]. 2010 Jul-Sept [cited 2014 Nov 18];2(3):117-22. 1.Watanabe E., Agostinho AM., Matsumoto W., Ito IY. Dental unit water: bacterial decontamination of old and new dental units by flushing water. International Journal of Dental Hygiene 2008; 6: 56-62.

20. Live and Let Microbes Die Our video: https://www.youtube.com/watch?v=6LpX3bItNI8&f eature=youtu.be