Comparison of the efficacies of disinfectants to control microbial contamination in dental unit water systems in general dental practices across the European Union

The consistent application of hydrogen peroxide controls biofilm growth and removes Vermamoeba vermiformis from multi-kingdom in-vitro dental unit water biofilms

The water systems inside a dental unit are known to be contaminated with a multi-kingdom biofilm encompassing bacteria, fungi, viruses and protozoa. Aerosolization of these micro-organisms can potentially create a health hazard for both dental staff and the patient. Very little is known on the efficacy of dental unit disinfection products against amoeba. In this study we have examined the effect of four different treatment regimens, with the hydrogen peroxide (H₂O₂) containing product Oxygenal, on an in-vitro multi-kingdom dental unit water system (DUWS) biofilm. The treatment efficacy was assessed in time using heterotrophic plate counts, the bacterial 16S rDNA, fungal 18S rDNA gene load and the number of genomic units for Legionella spp. the amoeba Vermamoeba vermiformis. The results indicated that a daily treatment of the DUWS with a low dose H₂O₂ (0.02% for 5 h), combined with a weekly shock dose (0.25% H₂O₂, 30 min) is necessary to reduce the heterotrophic plate count of a severely contaminated DUWS (>10⁶ CFU.mL^-1) to below 100 CFU.mL^-1. A daily treatment with a low dose hydrogen peroxide alone, is sufficient for the statistically significant reduction of the total amount of bacterial 16S rDNA gene, Legionella spp. and Vermamoeba vermiformis load (p < 0.005). Also shown is that even though hydrogen peroxide does not kill the trophozoite nor the cysts of V. vermiformis, it does however result in the detachment of the trophozoite form of this amoeba from the DUWS biofilm and hereby ultimately removing the amoeba from the system.

A pilot study comparing the disinfecting effects of commercialized stable ClO2 solution (free of activation) with conventional H2O2 on dental unit waterlines in the dental practice setting

Disinfection of dental unit waterlines (DUWLs) plays a key role in control and prevention of nosocomial infection in a dental clinic. The most conventional disinfectant is hydrogen peroxide (H2O2), while chlorine dioxide (ClO2) has been considered however was limited by the "activation" procedures. With the availability of commercialized stable ClO2 solution (free of activation), direct application of ClO2 in the dental practice became possible. This study was designed to compare the disinfecting effects of stable 5 ppm of ClO2 solution with conventional 0.24% of H2O2 on DUWLs in dental practice. Studies of colony-forming units (CFUs), confocal laser scanning microscopy (CLSM) and scanning electron microscope (SEM) were employed for evaluation. In CFUs studies, we found that the efficiency of ClO2 was no less than those of H2O2. In the morphological studies, the stronger disinfecting effects of ClO2 was verified by both CLSM and SEM studies for removal and prevention of biofilm. Importantly, ClO2 solution achieved a better disinfecting efficiency not only at the surface of bacterial biofilm, but also, it has penetrating effects, presented disinfecting effects from the surface to the bottom of the biofilm. This pilot study provided evidence regarding the efficiency of stable ClO2 solution on disinfection of DUWLs in the dental practice setting. Application of stable ClO2 solution in dental practice is therefore become possible.

The Effect of Hydrogen Peroxide Colloidal-Ag Used in Dental Unit Waterline on Shear Bond Strength of Orthodontic Brackets

BACKGROUND

The quality of the water passing through the water lines is crucial to dental procedures. Studies on bracket adhesion of hydrogen peroxide colloidal-Ag, which is widely used to prevent biofilm formation, are limited in the literature.

AIM

To determine whether disinfecting the dental units' waterlines (DUW) with hydrogen peroxide colloidal-Ag has any effect on the shear bond strength (SBS) of orthodontic brackets bonded to enamel.

MATERIALS AND METHODS

Sixty premolar teeth were divided randomly into two groups. The study and control groups consists of 30 teeth that were etched for 30 seconds with 37% phosphoric acid. Study groups washed with hydrogen peroxide colloidal-Ag water and the control group washed with municipal water. Transbond XT adhesive system was used to bond stainless steel brackets on all the teeth. A 300-g force was applied using a tension gauge to ensure a uniform adhesive thickness and light cured with 6 seconds. The SBS was quantified by means of a universal testing machine. The residual adhesive on the enamel surface was evaluated after debonding using the adhesive remnant index (ARI).

RESULTS

The t-test results indicated that there were no significant differences in the SBS. The comparison of the results of ARI scores was found statistically insignificant.

CONCLUSION

It has been found that hydrogen peroxide colloidal-Ag, which is used to reduce the amount of biofilm in DUW, does not have a negative effect on the adhesion of the brackets.

Construction of ZnO/PCL Antibacterial Coating Potentially for Dental Unit Waterlines

The formation of bacterial biofilms and the contamination of treatment water within dental unit waterlines can lead to a risk of secondary bacterial infections in immunocompromised patients. Although chemical disinfectants can reduce the contamination of treatment water, they can also cause corrosion damage to dental unit waterlines. Considering the antibacterial effect of ZnO, a ZnO-containing coating was prepared on the surface of polyurethane waterlines using polycaprolactone (PCL) with a good film-forming capacity. The ZnO-containing PCL coating improved the hydrophobicity of polyurethane waterlines, thus inhibiting the adhesion of bacteria. Moreover, the continuous slow release of Zn ions endowed polyurethane waterlines with antibacterial activity, thus effectively preventing the formation of bacterial biofilms. Meanwhile, the ZnO-containing PCL coating had good biocompatibility. The present study suggests that ZnO-containing PCL coating can realize a long-term antibacterial effect on the polyurethane waterlines by itself, providing a novel strategy for the manufacture of autonomous antibacterial dental unit waterlines.

Effectiveness of a Water Disinfection Method Based on Osmosis and Chlorine Dioxide for the Prevention of Microbial Contamination in Dental Practices

In dental clinics, the infections may be acquired through contaminated devices, air, and water. Aerosolized water may contain bacteria, grown into the biofilm of dental unit waterlines (DUWLs). We evaluated a disinfection method based on water osmosis and chlorination with chlorine dioxide (O-CD), applied to DUWL of five dental clinics. Municipal water was chlorinated with O-CD device before feeding all DUWLs. Samplings were performed on water/air samples in order to research total microbial counts at 22-37 °C, Pseudomonas aeruginosa, Legionella spp., and chlorine values. Water was collected from the taps, spittoons, and air/water syringes. Air was sampled before, during, and after 15 min of aerosolizing procedure. Legionella and P. aeruginosa resulted as absent in all water samples, which presented total microbial counts almost always at 0 CFU/mL. Mean values of total chlorine ranged from 0.18-0.23 mg/L. Air samples resulted as free from Legionella spp. and Pseudomonas aeruginosa. Total microbial counts decreased from the pre-aerosolizing (mean 2.1 × 10² CFU/m³) to the post-aerosolizing samples (mean 1.5 × 10 CFU/m³), while chlorine values increased from 0 to 0.06 mg/L. O-CD resulted as effective against the biofilm formation in DUWLs. The presence of residual activity of chlorine dioxide also allowed the bacteria reduction from air, at least at one meter from the aerosolizing source.

Disinfection methods of dental unit waterlines contamination: a systematic review

Background. Severe contamination of dental unit waterlines was found in healthcare settings. The benefits of decontamination methods are controversial. The aim of this review was to systematically evaluate disinfection methods in contamination control of dental unit waterlines.Methods. The terms 'dental unit waterline(s) or DUWL(s) or dental unit water line(s)' were searched through PubMed, Cochrane Library, Embase, Web of Science and Scopusup to 31 May 2021. The DUWLs' output water was incubated on R2A agar at 20-28 °C for 5-7 days to evaluate heterotrophic mesophilic bacteria. The risk of bias was evaluated by a modified Newcastle-Ottawa quality assessment scale.Results. Eighteen papers from the literature were included. One study indicated that water supply played a crucial role in disinfecting DUWLs. Three studies indicated that flushing decreased bacteria counts but did not meet the American CDC standard (500 c.f.u. ml^-1). All chlorine- and peroxide-containing disinfectants except sodium hypochlorite in one of 15 studies as well as three mouthrinses and citrus botanical extract achieved the standard (≤500 c.f.u. ml^-1). The included studies were of low (1/18), moderate (6/18) and high (11/18) quality.Conclusion. Independent water reservoirs are recommended for disinfecting DUWLs using distilled water. Flushing DUWLs should be combined with disinfections. Nearly all the chlorine-, chlorhexidine- and peroxide-containing disinfectants, mouthrinses and citrus botanical extract meet the standard for disinfecting DUWLs. Alkaline peroxide would lead to tube blockage in the DUWLs. Regularly changing disinfectants can reduce the risk of occurrence of disinfectant-resistant strains of microbes.

An Evaluation of Two Systems for the Management of the Microbiological Quality of Water in Dental Unit Waterlines: Hygowater® and IGN Calbénium®

Water in dental unit waterlines (DUWL) represents a risk for vulnerable patients if its microbiological quality is not controlled. The aim of this prospective study was to evaluate two systems for its management under real conditions: Hygowater® and IGN Calbenium®. Samples of the output water of DUWL were obtained for 5 previously contaminated units connected to Hygowater®, and 5 non-contaminated units connected to IGN Calbenium®, which was already effective for more than 1 year, as a control group. Samples were regularly collected up to 6 months after the implementation of Hygowater®, and were then cultured and analyzed. With IGN Calbenium®, except for a technical problem and a sample result in one unit at 6 months (Heterotrophic Plate Count (HPC) at 37 °C of 66 colony forming units (cfu)/mL), the results showed an absence of contamination. Hygowater® took a couple of weeks to be effective on initially contaminated DUWL (over 200 cfu/mL for all the units), then showed its efficacy for 2 months (HPC at 37 °C with a mean of 40.2 ufc/mL, and HPC at 22 °C with a mean of 0.2 ufc/mL). At 6 months, results were satisfactory for HPC at 22 °C (mean of 12 ufc/mL), but HPC at 37 °C gave non-satisfactory results for 4 of the 5 units (mean of 92.2 ufc/mL). Both systems have an effect on the microbiological quality of DUWL. IGN Calbenium® appears to be more reliable on a long-term basis.

Heterogeneity in the efficacy of dental chemical disinfectants on water-derived biofilms in vitro

Conditions in dental unit waterlines are favourable for biofilm growth and contamination of dental unit water. The aim of this study was to assess the effect of several chemical disinfectants on bacteria in a biofilm model. Water-derived biofilms were grown in a static biofilm model (Amsterdam Active Attachment model), using two growth media. Biofilms were challenged with Alpron/Bilpron, Anoxyl, Citrisil, Dentosept, Green & Clean, ICX and Oxygenal in shock dose and maintenance doses. The concentration and the composition of the chemical disinfectants influenced the number of culturable bacteria in the biofilms. The application of a single shock dose followed by a low dose of the same chemical disinfectants resulted in the greatest suppression of viable bacteria in the biofilms. Exposure to Citrisil and ICX consistently resulted in failure to control the biofilms, while Alpron/Bilpron had a substantial and relevant effect on the number of bacteria in the biofilms.

Efficacy of BRS® and Alpron®/Bilpron® Disinfectants for Dental Unit Waterlines: A Six-Year Study

Biofilms in dental unit waterlines (DUWL) are a potentially significant source of contamination posing a significant health risk as these may come into contact with patients and dental staff during treatment. The aim of this study was to evaluate the microbiological quality of DUWL water treated by Biofilm-Removing-System^® (BRS^®) and Alpron^®/Bilpron^® disinfectant solutions for six years in a French university hospital. The microbiological quality of water supplied by 68 dental units—initially shock treated with BRS^®, then continuously treated by Alpron^® with sterile water during working days and Bilpron^® during inactivity period, and combined with purging every morning and after each patient—was assessed biannually during six years for total culturable aerobic bacteria at 22 °C and 36 °C, Legionella sp., Pseudomonas aeruginosa, and total coliforms. A total of 628 samples were analyzed, 99.8% were compliant with extended microbiological levels, and we never detected pathogen bacteria like Legionella sp. and P. aeruginosa. Only one sample (0.2%) was noncompliant with the level of total culturable aerobic bacteria at 36 °C, which exceeded 140 colony forming units per mL. The protocol implemented in our university hospital gives excellent results and enables control of the microbiological quality of DUWL water in the long term.

Assessment of nosocomial bacterial contamination in dental unit waterlines: Impact of flushing

Purpose

This study evaluated the extent of bacterial contamination in water from dental unit waterlines (DUWLs).

Methodology

Water samples were collected (before flushing, 1 min post-flushing, and 3 min post-flushing) from 24 clinics (Group A: no disinfection, Group B: citric acid disinfectant) of a Government Dental College. Bacterial counts, identification, antibiotic sensitivity tests, determination of endotoxin levels, and scanning electron microscopy (to confirm the presence of biofilm) were performed.

Results

The most common opportunistic bacteria were P. aeruginosa (95%), S. aureus (58%), S. auricularis (49%), P. fluorescens (44%), and A. baumannii (20%). Approximately 50% of the bacterial isolates were resistant to two or more antibiotics. Flushing for 3 min did not reduce the contamination of water from Group A clinics which exceeded the recommendation of ≤500 CFU/ml. No bacterial growth was seen in Group B samples. Endotoxin levels were >5.00 endotoxin units (EU)/ml in Group A and ranged from 1.33 to 5.00 EU/ml in Group B clinics. Scanning electron microscopy images showed bacterial biofilms on the surfaces of the tubes.

Conclusions

DUWL contamination is a serious issue in dentistry, and the microbiological quality of the water must be monitored regularly. Further studies on endotoxin exposure and prevention are therefore necessary.

The role of chemical products at low doses in preventing the proliferation of bacteria in dental unit waterlines: the ICX® experience

In this study we evaluated (1) the efficacy of a protocol that combines hydrogen peroxide (shock treatment) and ICX^® tablets (continuous treatment) for the control of microbial contamination in dental unit water lines, and (2) the in vitro antimicrobial activity of ICX^® tablets on collection and wild strains isolated from dental chair output waters. To assess the treatment effectiveness, the microbial load in the output water samples of three dental chairs were investigated: one control chair received only shock treatment. In vitro bactericidal activity was tested against Staphylococcus aureus and Pseudomonas aeruginosa. Data obtained from samples collected from chairs treated with ICX^® and shock treatment and data from the control chair did not differ significantly on the basis of microbial load. In the in vitro study, the product was unable to kill Gram-negative bacteria. These results show that the continuous introduction of ICX^® was not effective in maintaining low counts of the heterotrophic bacteria in the output water of dental devices, and shock treatment may be needed more frequently than monthly.

Dental Unit Water Lines and their Disinfection and Management: A Review

The perceived threat to public health from dental unit water line (DUWL) contamination comes from opportunistic and respiratory pathogens such as Legionella spp, Nontuberculous Mycobacteria (NTM) and pseudomonads. These organisms can grow and multiply in the DUWL biofilm to reach infective concentrations, with the potential for inhalation leading to respiratory infections or direct contamination of surgical wounds. In this paper we discuss current legislation and practical methods for delivering water within the DUWL that meets the standards for safety. Clinical relevance: Understanding the clinical relevance and methods for decontaminating DUWL is essential to create a safe working environment in dentistry.

Establishing a laboratory model of dental unit waterlines bacterial biofilms using a CDC biofilm reactor

In this study, a laboratory model to reproduce dental unit waterline (DUWL) biofilms was developed using a CDC biofilm reactor (CBR). Bacteria obtained from DUWLs were filtered and cultured in Reasoner's 2A (R2A) for 10 days, and were subsequently stored at -70°C. This stock was cultivated on R2A in batch mode. After culturing for five days, the bacteria were inoculated into the CBR. Biofilms were grown on polyurethane tubing for four days. Biofilm accumulation and thickness was 1.3 × 10⁵ CFU cm^-2 and 10-14 μm respectively, after four days. Bacteria in the biofilms included cocci and rods of short and medium lengths. In addition, 38 bacterial genera were detected in biofilms. In this study, the suitability and reproducibility of the CBR model for DUWL biofilm formation were demonstrated. The model provides a foundation for the development of bacterial control methods for DUWLs.

Nanosilver as a disinfectant in dental unit waterlines: Assessment of the physicochemical transformations of the AgNPs

Dental unit water lines (DUWL) are susceptible to biofilm development and bacterial growth leading to water contamination, causing health and ecological effects. This study monitors the interactions between a commonly used nanosilver disinfectant (ASAP-AGX-32, an antimicrobial cleaner for dental units, 0.0032% Ag) and biofilm development in DUWL. To simulate the disinfection scenario, an in-house DUWL model was assembled and biofilm accumulation was allowed. Subsequent to biofilm development, the disinfection process was performed according to the manufacturer's instructions. The pristine nanosilver particles in the cleaner measured between 3 and 5 nm in diameter and were surrounded by a stabilizing polymer. However, the polymeric stabilizing agent diminished over the disinfection process, initiating partial AgNPs aggregation. Furthermore, surface speciation of the pristine AgNPs were identified as primarily AgO, and after the disinfection process, transformations to AgCl were observed. The physicochemical characteristics of AgNPs are known to govern their fate, transport and environmental implications. Hence, knowledge of the AgNPs characteristics after the disinfection process (usage scenario) is of significance. This study demonstrates the adsorption of AgNPs onto biofilm surfaces and, therefore, will assist in illustration of the toxicity mechanisms of AgNPs to bacteria and biofilms. This work can be an initial step in better understanding how AgNPs transform depending on the conditions they are exposed to during their lifetime. Until this date, most research has been focused on assessing the impacts of pristine (lab synthesized) nanomaterials on various systems. However, it is our belief that nanoparticles may undergo transformations during usage, which must be taken into consideration. Furthermore, this experiment is unique as it was conducted with a commonly used, commercially available nanosilver suspension leading to more realistic and applicable findings.

The practice of disinfection of high-speed handpieces with 70% w/v alcohol: An evaluation

A high-speed handpiece is used in several dental procedures and the official recommendation for safe decontamination consists of rinsing with water, washing with detergent, mechanical friction, and sterilization; however, many professionals only apply 70% w/v alcohol without also cleaning the tool between patients. We performed an analysis of high-speed handpieces reprocessed only with 70% w/v alcohol and found that the methods used in clinical practice are not safe.

Contamination of dental unit waterlines: assessment of three continuous water disinfection systems

OBJECTIVES

To assess the efficacy of three continuous water disinfection systems for dental units under real conditions of dental care.

DESIGN AND SETTINGS

A prospective study carried out from 45 days to 20 months on the water microbial quality of the dental units is benefited from three different systems: two chemical treatment systems (IGN EVO/Calbenium/IGN Cartridge and Sterispray) and one physical treatment system (BacTerminator). Studied items were six dental units of the Dental Medicine and Oral Surgery Center within the University Hospital of Strasbourg (HUS), France.

RESULTS AND DISUCUSSION

The IGN EVO/Calbenium/IGN Cartridge and Sterispray systems showed an immediate and long-term efficacy on contaminated dental unit waterlines. However, the first system offers ergonomic advantages (automatic system, action on the water from the water supply network). The BacTerminator system took longer to be effective and was less effective than the other two.

Occurrence and diversity of both bacterial and fungal communities in dental unit waterlines subjected to disinfectants

Chemical disinfectants are widely advocated to reduce the microbial contamination in dental unit waterlines (DUWL). However, until now their efficacy has been poorly examined after long-term application. In this study, through quantitative PCR and high-throughput sequencing, both bacterial and fungal communities were profiled from 8- to 12-year-old DUWL treated with disinfectants commonly used by European dentists. Water was collected from the tap water supplying units to the output exposure point of the turbine handpiece following a stagnation period and dental care activity. Results showed that (i) the unit itself is the principal source of microbial contamination and (ii) water stagnation, DU maintenance practices and quality of water supplying DU appeared as parameters driving the water quality. Despite disinfecting treatment combined to flushing process, the microbial contamination remained relevant in the studied output water, in association with a high bacterial and fungal diversity. The occurrence of potentially pathogenic microorganisms in these treated DUWL demonstrated a potential infectious risk for both patients and dental staff. A disinfectant shock before a prolonged stagnation period could limit the microbial proliferation inside DUWL. Necessity to proceed to regular water quality control of DUWL was highlighted.

Efficacy of a Low Dose of Hydrogen Peroxide (Peroxy Ag⁺) for Continuous Treatment of Dental Unit Water Lines: Challenge Test with Legionella pneumophila Serogroup 1 in a Simulated Dental Unit Waterline

This study was designed to examine the in vitro bactericidal activity of hydrogen peroxide against Legionella. We tested hydrogen peroxide (Peroxy Ag⁺) at 600 ppm to evaluate Legionella survival in a simulated dental treatment water system equipped with Water Hygienization Equipment (W.H.E.) device that was artificially contaminated. When Legionella pneumophila serogroup (sg) 1 was exposed to Peroxy Ag⁺ for 60 min we obtained a two decimal log reduction. High antimicrobial efficacy was obtained with extended periods of exposure: four decimal log reduction at 75 min and five decimal log reduction at 15 h of exposure. Involving a simulation device (Peroxy Ag⁺ is flushed into the simulation dental unit waterlines (DUWL)) we obtained an average reduction of 85% of Legionella load. The product is effective in reducing the number of Legionella cells after 75 min of contact time (99.997%) in the simulator device under test conditions. The Peroxy Ag⁺ treatment is safe for continuous use in the dental water supply system (i.e., it is safe for patient contact), so it could be used as a preventive option, and it may be useful in long-term treatments, alone or coupled with a daily or periodic shock treatment.

Breaking the Chain of Infection: Dental Unit Water Quality Control

INTRODUCTION

The air-water syringes, ultrasonic scalers, high speed air turbine handpieces are connected to dental units by a network of small-bore plastic tubes through which water and air travel to activate or cool the instruments and it had been shown that this system is extensively contaminated with microbial biofilms and pose a potential risk of infection for patients as well as dental professionals.

AIM

To evaluate and compare the efficacy of various disinfectants in reducing the microbial colony count in water derived from Dental Unit Waterlines.

MATERIALS AND METHODS

Five random dental units were selected and samples were collected before and after intervention with 5 disinfectants (0.02% H2O2 continuously, 0.02% H2O2 continuously with shock treatment with 0.25% H2O2 weekly, 0.12% Chlorohexidine and 12% Ethanol overnight, 1:50 Original Listerine overnight, 2% Sodium Perborate and 2% EDTA 5 minutes in morning) using different disinfection methods for 4 weeks. Samples were cultured on Reasoner's 2A (R2A) agar for microbial counting.

RESULTS

Results were recorded as Colony forming units/ml (cfu/ml) and were evaluated statistically. Results showed that all the dental unit waterlines were heavily contaminated with microbes before any intervention. After 1 day of disinfection regime the counts reduced significantly and showed progressive reduction in consecutive weeks. Goals set by ADA & CDC were ultimately achieved at the end of 4 weeks.

CONCLUSION

All the disinfectants were equally effective in reducing the microbial colony count of DUWLs, irrespective of their concentration and method of disinfection.

Efficacy of dental unit waterlines disinfectants on a polymicrobial biofilm

Due to their high surface-volume ratio, their laminar flow and frequent stagnation periods, dental unit waterlines (DUWL) foster the attachment of microorganisms and the development of biofilm, resulting in the continuous contamination of the outlet water from dental units; this contamination may be responsible for a potential risk of infection due to the exposure of patients and medical staff to droplet inhalation or splashed water. In this study, the anti-biofilm activity of three disinfectants recommended by dental unit manufacturers -Calbenium(©), Oxygenal 6(©) and Sterispray(©) - was evaluated. A dynamic model simulating DUWL conditions was developed and polymicrobial biofilms containing bacteria (Pseudomonas aeruginosa), fungi (Candida albicans) and Free Living Amoeba (FLA: Vermamoeba vermiformis) were allowed to form. The ability of disinfectants to reduce biofilm formation or to eradicate an already formed biofilm was evaluated. Results showed the various effects of the tested disinfectants according to their composition, concentration and the targeted species. V. vermiformis was resistant to disinfectants, regardless of the tested concentrations and the concentrations recommended by manufacturers were not the most appropriate. Results also showed that Calbenium(©) was the most effective disinfectant to reduce already formed biofilms; its maximum efficiency was observed from 0.5% on both P. aeruginosa and C. albicans compared to 2 and 3% respectively for Sterispray(©). The maximum efficiency of Oxygenal(©) was observed from 3% on P. aeruginosa but Oxygenal(©) was unable to totally eliminate C. albicans in the tested conditions, contrary to other disinfectants. Calbenium(©) was able to prevent biofilm formation efficiently even if it displayed no prophylactic activity against V. vermiformis. Overall, the FLA survival may contribute to maintaining other species. Finally the tested disinfectants were partially active against sessile microorganisms and more suitable concentrations could be used to increase their efficacy. Their use in a prophylactic rather than curative way should be recommended.

Microbial control of dental unit water: Feedback on different disinfection methods experience

A water quality study of dental units showed biofilm and opportunistic microorganisms. We report the steps that ultimately allowed us to obtain water quality as water for standard care with no pathogens throughout all dental units. In summary, treatment with continuous disinfection associated with use of sterile water allowed us to restore the water quality at the output of dental care units while ensuring the safety of care.

Pyrosequencing analysis of bacterial diversity in dental unit waterlines

Some infections cases due to exposure to output water from dental unit waterlines (DUWL) have been reported in the literature. However, this type of healthcare-associated risk has remained unclear and up until now the overall bacterial composition of DUWL has been poorly documented. In this study, 454 high-throughput pyrosequencing was used to investigate the bacterial community in seven dental offices (N = 7) and to identify potential bacterial pathogenic sequences. Dental unit waters (DUW) were collected from the tap water supplying units (Incoming Water; IW) to the output exposure point of the turbine handpiece (Output water; OW) following a stagnation period (OWS), and immediately after the last patient of the sampling day (OWA). A high bacterial diversity was revealed in DUW with 394 operational taxonomic units detected at the genus level. In addition to the inter-unit variability observed, results showed increased total bacterial cell concentration and shifts in bacterial community composition and abundance at the genus level, mainly within the Gamma- and Alpha-Proteobacteria class, as water circulated in the dental unit (DU). Results showed that 96.7%, 96.8% and 97.4% of the total sequences from IW, OWS and OWA respectively were common to the 3 defined water groups, thereby highlighting a common core microbiome. Results also suggested that stagnation and DU maintenance practices were critical to composition of the bacterial community. The presence of potentially pathogenic genera was detected, including Pseudomonas and Legionella spp. Emerging and opportunistic pathogenic genera such as Mycobacterium, Propionibacterium and Stenotrophomonas were likewise recovered in DUW. For the first time, an exhaustive evaluation of the bacterial communities present in DUW was performed taking into account the circulation of water within the DU. This study highlights an ignored diversity of the DUWL bacterial community. Our findings also contribute to a better appreciation of the potential infectious risk associated with dental care and suggest the importance of better managing microbial quality in DUW.

Antibacterial Properties and Mechanism of Activity of a Novel Silver-Stabilized Hydrogen Peroxide

Huwa-San peroxide (hydrogen peroxide; HSP) is a NSF Standard 60 (maximum 8 mg/L(-1)) new generation peroxide stabilized with ionic silver suitable for continuous disinfection of potable water. Experiments were undertaken to examine the mechanism of HSP against planktonic and biofilm cultures of indicator bacterial strains. Contact/kill time (CT) relationships that achieve effective control were explored to determine the potential utility in primary disinfection. Inhibitory assays were conducted using both nutrient rich media and a medium based on synthetic wastewater. Assays were compared for exposures to three disinfectants (HSP, laboratory grade hydrogen peroxide (HP) and sodium hypochlorite) at concentrations of 20 ppm (therefore at 2.5 and 5 times the NSF limit for HP and sodium hypochlorite, respectively) and at pH 7.0 and 8.5 in dechlorinated tap water. HSP was found to be more or equally effective as hypochlorite or HP. Results from CT assays comparing HSP and HP at different bacterial concentrations with neutralization of residual peroxide with catalase suggested that at a high bacterial concentration HSP, but not HP, was protected from catalase degradation possibly through sequestration by bacterial cells. Consistent with this hypothesis, at a low bacterial cell density residual HSP was more effectively neutralized as less HSP was associated with bacteria and therefore accessible to catalase. Silver in HSP may facilitate this association through electrostatic interactions at the cell surface. This was supported by experiments where the addition of mono (K(+)) and divalent (Ca(+2)) cations (0.005-0.05M) reduced the killing efficacy of HSP but not HP. Experiments designed to distinguish any inhibitory effect of silver from that of peroxide in HSP were carried out by monitoring the metabolic activity of established P. aeruginosa PAO1 biofilms. Concentrations of 70-500 ppm HSP had a pronounced effect on metabolic activity while the equivalent concentrations of ionic silver (50- 375 ppb) had a negligible effect, demonstrating that the microbiocidal activity of HSP was due to peroxide rather than silver. Overall, it was found that the antimicrobial activity of HSP is enhanced over that of hydrogen peroxide; the presence of the ionic silver enhances interactions of HSP with the bacterial cell surface rather than acting directly as a biocide at the tested concentrations.

Monitoring the decontamination efficacy of the novel Poseidon-S disinfectant system in dental unit water lines

BACKGROUND

Contaminated dental unit waterlines (DUWLs) are a known source of specific health care-acquired infections because of the difficulty in keeping them clean during routine dental practice. Recently, an electrolysis apparatus that uses only the chlorine normally present in municipal water, the Poseidon-S system, was developed as a novel additive-free disinfectant system to control microbial contamination in DUWLs.

METHODS

The microbiological quality of water samples collected from DUWLs was assessed before and after installation of the Poseidon-S system in terms of the total viable counts (TVCs) of microorganisms. The microbicidal effects of the electrolyzed water against oral organisms and its cytotoxicity against human oral-derived cell lines were also examined.

RESULTS

Water samples from the DUWLs initially had average microbial TVCs of 10³-10⁶ colony-forming units (CFU)/mL. After installation of the Poseidon-S system, the number of microorganisms in the water samples decreased to less than 1 × 10² CFU/mL. The electrolyzed water also exhibited remarkable microbicidal effects on the microorganisms present in the DUWLs as well as microorganisms commonly isolated from human oral cavities, but showed low cytotoxicity towards human oral-derived cells.

CONCLUSION

This study demonstrated that routine use of the Poseidon-S system can effectively maintain low microbial levels in DUWLs.

Biofouling of surgical power tools during routine use

Surgical power tools (SPTs) are frequently used in many surgical specialties such as dentistry, orthopaedics, ophthalmology, neurology, and podiatry. They have complex designs that may restrict access to cleaning and sterilization agents and frequently become contaminated with microbial and tissue residues following use. Due to these challenges, surgical power tools can be considered the weak link in the decontamination cycle and present a potential for iatrogenic transmission of infection. We aimed to review the existing literature on the decontamination of surgical power tools and associated iatrogenic transmission of infection. A search of the medical literature was performed using Ovid online using the following databases: Ovid Medline 1950-2014, Embase 1980-2014, and EBM Reviews Full Text--Cochrane DSR, ACP Journal Club, and Dare. Despite challenges to decontamination processes, reported episodes of iatrogenic infection directly linked to SPTs appear rare. This may reflect a true picture but more likely represents incomplete reporting, failure to investigate power tools, or lack of surveillance linking surgical site infections (SSIs) to power tools. Healthcare professionals should be aware of the complexities associated with the decontamination of different SPTs, and should review manufacturers' reprocessing instructions prior to purchase. More clarity is required in the manufacturers' validation of these reprocessing instructions. This particularly applies to the emerging surgical robot systems that present extreme challenges to decontamination between uses. Investigation of cross-infection incidents or SSI surveillance should include an element of assessment of SPT decontamination to further elucidate the contribution of SPTs to skin and soft tissue infections.

Impact of a risk management plan on Legionella contamination of dental unit water

The study aimed to assess the prevalence of Legionella spp. in dental unit waterlines of a dental clinic and to verify whether the microbiological parameters used as indicators of water quality were correlated with Legionella contamination. A risk management plan was subsequently implemented in the dental health care setting, in order to verify whether the adopted disinfection protocols were effective in preventing Legionella colonization. The water delivered from syringes and turbines of 63 dental units operating in a dental clinic, was monitored for counts of the heterotrophic bacteria P. aeruginosa and Legionella spp. (22 °C and 37 °C). At baseline, output water from dental units continuously treated with disinfection products was more compliant with the recommended standards than untreated and periodically treated water. However, continuous disinfection was still not able to prevent contamination by Legionella and P. aeruginosa. Legionella was isolated from 36.4%, 24.3% and 53.3% of samples from untreated, periodically and continuously treated waterlines, respectively. The standard microbiological parameters used as indicators of water quality proved to be unreliable as predictors of the presence of Legionella, whose source was identified as the tap water used to supply the dental units. The adoption of control measures, including the use of deionized water in supplying the dental unit waterlines and the application of a combined protocol of continuous and periodic disinfection, with different active products for the different devices, resulted in good control of Legionella contamination. The efficacy of the measures adopted was mainly linked to the strict adherence to the planned protocols, which placed particular stress on staff training and ongoing environmental monitoring.

Effect of different disinfection protocols on microbial and biofilm contamination of dental unit waterlines in community dental practices

Output water from dental unit waterlines (DUWLs) may be a potential source of infection for both dental healthcare staff and patients. This study compared the efficacy of different disinfection methods with regard to the water quality and the presence of biofilm in DUWLs. Five dental units operating in a public dental health care setting were selected. The control dental unit had no disinfection system; two were disinfected intermittently with peracetic acid/hydrogen peroxide 0.26% and two underwent continuous disinfection with hydrogen peroxide/silver ions (0.02%) and stabilized chlorine dioxide (0.22%), respectively. After three months of applying the disinfection protocols, continuous disinfection systems were more effective than intermittent systems in reducing the microbial contamination of the water, allowing compliance with the CDC guidelines and the European Council regulatory thresholds for drinking water. P. aeruginosa, Legionella spp, sulphite-reducing Clostridium spores, S. aureus and β-haemolytic streptococci were also absent from units treated with continuous disinfection. The biofilm covering the DUWLs was more extensive, thicker and more friable in the intermittent disinfection dental units than in those with continuous disinfection. Overall, the findings showed that the products used for continuous disinfection of dental unit waterlines showed statistically better results than the intermittent treatment products under the study conditions.

Efficacy of dental unit disinfectants against Candida spp. and Hartmannella vermiformis

Human oral commensal Candida yeasts, as well as environmental free-living amoebae (FLA) such as Hartmannella, are known to be direct or indirect human pathogens. These microorganisms may be isolated from dental unit waterlines (DUWL), because of contamination coming from the tap water and/or a patient's mouth. This study compared the efficacy of commonly used DUWL disinfectants (chlorine, H2 O2 , and Oxygenal 6©) against three species of Candida (C. albicans, C. glabrata, and C. parapsilosis) and one FLA species (H. vermiformis), growing either as single or as mixed biofilms in tap water. Results showed variable efficacies: H2 O2 had no significant activity, while chlorine was effective but only at the highest doses tested, probably not compatible with DUWL uses. Oxygenal 6© was the most efficacious in preventing the growth of yeasts in tap water. However, in the presence of FLA, Oxygenal 6© displayed a reduced antimicrobial activity against sessile C. albicans. In conclusion, none of the tested disinfectants could eradicate yeasts or FLA. Moreover, the antiyeast activity of Oxygenal 6© was reduced in the presence of FLA. Both sessile or planktonic and mixed or single-species conditions should be considered when evaluating the activity of disinfectants for DUWL maintenance. This study also highlighted that FLA should be included in the testing protocols.

Spatial arrangement of legionella colonies in intact biofilms from a model cooling water system

There is disagreement among microbiologists about whether Legionella requires a protozoan host in order to replicate. This research sought to determine where in biofilm Legionellae are found and whether all biofilm associated Legionella would be located within protozoan hosts. While it is accepted that Legionella colonizes biofilm, its life cycle and nutritional fastidiousness suggest that Legionella employs multiple survival strategies to persist within microbial systems. Fluorescent in situ hybridization (FISH) and confocal laser scanning microscopy (CLSM) demonstrated an undulating biofilm surface architecture and a roughly homogenous distribution of heterotrophic bacteria with clusters of protozoa. Legionella displayed 3 distinct spatial arrangements either contained within or directly associated with protozoa, or dispersed in loosely associated clusters or in tightly packed aggregations of cells forming dense colonial clusters. The formation of discreet clusters of tightly packed Legionella suggests that colony formation is influenced by specific environmental conditions allowing for limited extracellular replication. This work represents the first time that an environmentally representative, multispecies biofilm containing Legionella has been fluorescently tagged and Legionella colony morphology noted within a complex microbial system.

Purge- and intensive-purge decontamination of dental units contaminated with biofilm

Introduction: During hygienic-microbiological monitoring of the water quality in dental units, the total bacterial colony count was found to exceed the limits for drinking water quality; in addition, mold contamination was detected. The presumed cause was irregular decontamination of the units through purging and intensive decontamination.

Methods: To decontaminate the units, the manufacturer’s recommended program for cleaning and intensive decontamination was intensified by shortened intervals over a 2-week period. For Sirona units, instead of once a day, the automatic purge program was run every morning and evening for 20 min each time, and instead of once a month, intensive decontamination was performed every two weeks; this schedule has been maintained since then. For KaVo units, cleaning with the hydroclean function was carried out for 2.5 min every morning and evening. The automatic intensive decontamination was run daily instead of weekly. A maintenance log book was introduced, in which decontamination/cleaning was confirmed by the operator’s signature.

Results: Within 5 weeks, all previously contaminated units were decontaminated.

Discussion: By shortening the cleaning and intensive decontamination intervals in a 2-week period with subsequent control that the recommended maintenance intervals were kept, it was possible to guarantee drinking-water quality in the dental units of both manufacturers.

Microbial environmental contamination in Italian dental clinics: A multicenter study yielding recommendations for standardized sampling methods and threshold values

A microbiological environmental investigation was carried out in ten dental clinics in Italy. Microbial contamination of water, air and surfaces was assessed in each clinic during the five working days, for one week per month, for a three-month period. Water and surfaces were sampled before and after clinical activity; air was sampled before, after, and during clinical activity. A wide variation was found in microbial environmental contamination, both within the participating clinics and for the different sampling times. Before clinical activity, microbial water contamination in tap water reached 51,200cfu/mL (colony forming units per milliliter), and that in Dental Unit Water Systems (DUWSs) reached 872,000cfu/mL. After clinical activity, there was a significant decrease in the Total Viable Count (TVC) in tap water and in DUWSs. Pseudomonas aeruginosa was found in 2.38% (7/294) of tap water samples and in 20.06% (59/294) of DUWS samples; Legionella spp. was found in 29.96% (89/297) of tap water samples and 15.82% (47/297) of DUWS samples, with no significant difference between pre- and post-clinical activity. Microbial air contamination was highest during dental treatments, and decreased significantly at the end of the working activity (p<0.05). The microbial buildup on surfaces increased significantly during the working hours. This study provides data for the establishment of standardized sampling methods, and threshold values for contamination monitoring in dentistry. Some very critical situations have been observed which require urgent intervention. Furthermore, the study emphasizes the need for research aimed at defining effective managing strategies for dental clinics.

A 10-year survey of compliance with recommended procedures for infection control by dentists in Beijing

OBJECTIVES

This study aimed to survey changes in practices of infection control (IC) procedures by dentists in Beijing between 2000 and 2010.

METHODS

Data were based on the feedback of 592 and 769 dentists surveyed in 2000 and 2010, respectively. Statistical analysis was conducted using Pearson's chi-squared test.

RESULTS

Response rates of 95% (2000) and 94% (2010) were achieved. The percentages of dentists who had received training in IC were 62.96% (2000) and 76.21% (2010). Improvements in practices in 2010 over those in 2000 included increases in: the percentage of vaccination for hepatitis B virus from 32.66% to 68.14%; the routine use of gloves from 73.31% to 99.73%; the use of face shields or eyewear as protection against splatter during dental treatment from 13.94% to 95.45%; the use of protective gowns from 14.51% to 54.23%; the use of high-volume suction from 11.19% to 74.34%; routine changing of gloves between patients from 63.25% to 99.22%; pressured steam sterilisation of dental handpieces between patients from 41.24% to 96.10%, and the flushing of dental unit waterlines after each treatment from 42.01% to 73.49%.

CONCLUSIONS

  Although compliance with recommended IC practices by dentists in Beijing improved between 2000 and 2010, not all dentists are properly familiar with IC procedures. Education in IC in dental schools and in continuing training in hospitals, and mandatory regulations are needed to improve IC practices in dental health care settings.

Management of dental unit waterline biofilms in the 21st century

Dental chair units (DCUs) use water to cool and irrigate DCU-supplied instruments and tooth surfaces, and provide rinsewater during dental treatment. A complex network of interconnected plastic dental unit waterlines (DUWLs) supply water to these instruments. DUWLs are universally prone to microbial biofilm contamination seeded predominantly from microorganisms in supply water. Consequently, DUWL output water invariably becomes contaminated by high densities of microorganisms, principally Gram-negative environmental bacteria including Pseudomonas aeruginosa and Legionella species, but sometimes contain human-derived pathogens such as Staphylococcus aureus. Patients and staff are exposed to microorganisms from DUWL output water and to contaminated aerosols generated by DCU instruments. A wide variety of approaches, many unsuccessful, have been proposed to control DUWL biofilm. More recently, advances in biofilm science, chemical DUWL biofilm treatment agents, DCU design, supply water treatment and development of automated DUWL biofilm control systems have provided effective long-term solutions to DUWL biofilm control.

An audit improves the quality of water within the dental unit water lines of general dental practices across the East of England

OBJECTIVE

To evaluate and improve upon the quality of water emanating from the dental unit waterlines (DUWLs) which supply irrigation for dental handpieces and triple spray syringes in general practice.

DESIGN

A prospective clinical audit.

SETTING

Seventy-two general dental practices in the East of England.

METHODS

In 2006, 124 dentists initially registered to participate in the audit. By 2007, 72 had begun and by 2008, 68 had completed the project. This involved collecting samples of water discharged from the DUWLs in the dental practices both before the start and mid-way through a morning session. These were tested microbiologically at a United Kingdom Accreditation Service testing laboratory.

INTERVENTIONS

Before the audit, 56% of the DUWLs were reportedly flushed through for 2 minutes at the start of the day, 29% were purged for 20 seconds in between each patient, 50% were treated with a wide range of different disinfectant solutions, 44% were drained down dry at the end of the day and 9% had no cross-infection control measures applied to them at all. In the audit, 100% used a disinfectant solution alone, predominantly either Alpron or Sterilox.

MAIN OUTCOME MEASURES

The minimum audit standard set was for the water samples to meet the United States' Centers for Disease Control and Prevention (CDC) guideline on the quality of DUWL water, namely that the United States' Environmental Protection Agency (EPA) regulatory standards for drinking water be adopted, in that no more than 5% of water samples should be contaminated with total coliforms and that they should not have more than 500 colony forming units per ml (cfu/ml) of heterotrophic water bacteria. However, the participating dentists were encouraged to try and achieve the more stringent European Union (EU) standards for potable (drinking) water, namely for the water samples to have neither Escherichia coli nor any other faecal coliforms present and for the aerobic colony count to be less than 100 cfu/ml at 22°C after 72 hours of culturing.

RESULTS

In the pre-audit survey, none of the 72 DUWL water samples were contaminated with E. coli but in five of them (7%) coliforms were recovered. Only 25% reached the EU potable water standard, of which 11% had zero planktonic bacterial contamination. Three percent were above the EU standard but below the CDC guideline/EPA regulatory drinking water standard, while alarmingly, 72% of them failed to reach this minimum audit standard altogether. However, after the application of a suitable disinfectant for at least a month, the audit revealed that E. coli still remained absent in the water samples taken from the 68 DUWLs that completed the project and in only one (1.5%) were coliforms recovered. Remarkably, nearly 81% reached the EU potable water standard, of which 54% had zero planktonic bacterial contamination, with nearly an additional 6% reaching the American CDC/EPA standard and with only 13% failing outright.

CONCLUSIONS

Clinical audit using appropriate DUWL disinfectants can result in the improvement of the quality of water that is discharged through DUWLs, thereby minimising both the risk of cross-infection to vulnerable patients as well as to dental staff chronically exposed to contaminated aerosols.

Comparison of the microbial load of incoming and distal outlet waters from dental unit water systems in Istanbul

This is a cross-sectional study of the incoming and distal outlet water quality from 41 dental units in Istanbul, carried out to compare the total microbial loads using traditional culture method versus epifluorescence microscopy. The possible presence of Legionella pneumophila using traditional culture method was also analyzed. One hundred and twenty three samples were taken from the high-speed handpiece lines, air-water syringe lines and source (incoming) water supplies from 41 dental units. The samples were assayed for live/dead bacteria, heterotrophic bacterial counts and presence of L. pneumophila bacteria. Thirty nine out of 41 dental units (91%) were not able to meet the standard limit of 200 CFU/ml in dental unit waters. The live bacterial counts were 1-1.5 orders of magnitude higher than aerobic mesophilic heterotrophic bacteria. L. pneumophila (serogroup 2-14) was isolated from five out of 41 units. Some dental units were using commercially bottled (19 l) drinking water as a source. The source water of eight dental unit was heavily contaminated which were fed up by commercially bottled drinking water.

Control of microbial contamination in dental unit water systems using tetra-sodium EDTA

AIM

To examine the efficacy of tetra-sodium EDTA in controlling microbial contamination of dental unit water systems (DUWS).

METHODS AND RESULTS

Ten dental units were treated once a week with either 4% or 8% tetra-sodium EDTA for four or two consecutive weeks, respectively. Before treatment, 43% and 60% of the water samples from the air/water triple syringe and high-speed hand-pieces, respectively, exceeded the American Dental Association (ADA) guidelines of 200 CFU ml(-1) water during a 6-week baseline period. After each weekend treatment, the levels of microbial contamination in all DUWS fell significantly (P < 0.001) to below the ADA guideline. By the end of the week, microbial counts in the outflowing water had returned to baseline levels indicating a transient effect of single doses of tetra-sodium EDTA, and the need for multiple applications. The biofilms were virtually eliminated after a single weekend treatment.

CONCLUSIONS

Tetra-sodium EDTA is effective in controlling microbial contamination in DUWS.

SIGNIFICANCE AND IMPACT OF THE STUDY

Inexpensive, effective and safe products for reducing the microbial load of water from DUWS are needed to meet ADA and other national guidelines. Tetra-sodium EDTA can significantly reduce microbial biofilms and bacterial counts in outflowing water, and is compatible for use in DUWS.

Italian multicenter study on infection hazards during dental practice: control of environmental microbial contamination in public dental surgeries

Background

The present study assessed microbial contamination in Italian dental surgeries.

Methods

An evaluation of water, air and surface microbial contamination in 102 dental units was carried out in eight Italian cities.

Results

The findings showed water microbial contamination in all the dental surgeries; the proportion of water samples with microbial levels above those recommended decreased during working. With regard to Legionella spp., the proportion of positive samples was 33.3%. During work activity, the index of microbial air contamination (IMA) increased. The level of microbial accumulation on examined surfaces did not change over time.

Conclusion

These findings confirm that some Italian dental surgeries show high biocontamination, as in other European Countries, which highlights the risk of occupational exposure and the need to apply effective measures to reduce microbial loads.

Antibiofilm activity of sodium bicarbonate, sodium metaperiodate and SDS combination against dental unit waterline-associated bacteria and yeast

AIM

To determine the effect of sodium bicarbonate (SB), sodium metaperiodate (SMP) and sodium dodecyl sulfate (SDS) combination on biofilm formation and dispersal in dental unit waterline (DUWL)-associated bacteria and yeast.

METHODS AND RESULTS

The in vitro effect of SB, SMP and SDS alone and in combination on biofilm formation and dispersal in Pseudomonas aeruginosa, Klebsiella pneumoniae, Actinomyces naeslundii, and Candida albicans was investigated using a 96-well microtitre plate biofilm assay. The combination showed a broad-spectrum inhibitory effect on growth as well as biofilm formation of both gram-negative and gram-positive bacteria, and yeast. In addition, the SB + SMP + SDS combination was significantly more effective in dispersing biofilm than the individual compounds. The combination dispersed more than 90% of P. aeruginosa biofilm whereas the commercial products, Oxygenal 6, Sterilex Ultra, and PeraSafe showed no biofilm dispersal activity.

CONCLUSION

The composition comprising SB, SMP, and SDS was effective in inhibiting as well as dispersing biofilms in DUWL-associated bacteria and yeast.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study shows that a composition comprising environmentally friendly and biologically safe compounds such as SB, SMP, and SDS has a potential application in reducing DUWL-associated acquired infections in dental clinics.

The role of manufacturers in reducing biofilms in dental chair waterlines

OBJECTIVES

This paper reviews how dental chair unit (DCU) manufacturers can contribute practically to resolving the problem of biofilm formation in dental unit waterlines (DUWs).

STUDY SELECTION

The review concentrates on how novel developments and changes in a range of specific areas have, and might contribute to DUW biofilm control. These include (i) DCU engineering and design changes; (ii) improvements to DCU supply water quality; (iii) development of automated DUW treatment procedures that are effective at controlling biofilm in the long-term, safe for patients and dental staff, environmentally friendly and which do not exhibit adverse effects on DCU components after prolonged use.

SOURCES

The majority of the material contained in this review is based on, or supported by the peer-reviewed literature.

DATA

The current consensus from the literature reveals that the emphasis on DUW biofilm and its control has focused on describing the problem and its control using a range of periodic and residual DUW treatment agents. Unfortunately, until recently, DCU manufacturers have provided very little specific guidance in this regard. Indeed, ensuring that DCUs provide good quality output water has generally been regarded to be the responsibility of dental practitioners. Some recent studies have shown that novel DCUs with integral semi-automated or automated DUW cleaning systems can effectively control DUW biofilm in the long-term. However, there are other potential DCU engineering and design changes that DCU manufacturers could undertake to further improve DUW biofilm control.

CONCLUSIONS

DCU manufacturers can significantly contribute to controlling the problem of DUW biofilm.

Microbial biofilm formation in DUWS and their control using disinfectants

OBJECTIVES

Due to the presence of extended narrow bore tubing and long periods of stagnation, dental unit water systems (DUWs) can be prone to relatively high levels of microbial contamination, including the formation of biofilm and the presence of opportunistic pathogens, irrespective of the source and quality of the inflowing water. Whilst the European Union (EU) has yet to set a definitive microbiological guideline, the American Dental Association (ADA) has set a maximum of <200 colony forming units (cfu)/ml for DUWs water in the USA. The objective of this review is to discuss why microbial contamination and biofilms are so prevalent in DUWs, as well as the role of disinfectants and their potential for achieving microbial water quality levels recommended by the ADA.

STUDY SELECTION

The review outlines the principal factors responsible for biofilm formation in DUWs and a number of mechanisms used for microbial control.

SOURCES

The source material contained in this review is taken from the peer-reviewed literature.

DATA

A variety of disinfectants are available for use, but controlled laboratory and clinical studies have shown that they can vary markedly in their efficacy and suitability for use. Some products have been shown to successfully remove biofilm and consistently reduce the microbial load of out-flowing water to <200 cfu/ml.

CONCLUSIONS

The effective delivery of approved disinfectants can control the level of microorganisms in DUWs at acceptable levels.

Optimisation of the long-term efficacy of dental chair waterline disinfection by the identification and rectification of factors associated with waterline disinfection failure

Although many studies have highlighted the problem of biofilm growth in dental chair unit waterlines (DUWs), no long-term studies on the efficacy of DUW disinfection using a large number of dental chair units (DCUs) have been reported.

OBJECTIVES

To investigate the long-term (21 months) efficacy of the Planmeca Waterline Cleaning System (WCS) to maintain the quality of DUW output water below the American Dental Association (ADA) recommended standard of < or =200cfu/mL of aerobic heterotrophic bacteria using once weekly disinfection with the hydrogen peroxide-and silver ion-containing disinfectant Planosil.

METHODS

Microbiological quality of DUW output water was monitored by culture on R2A agar for 10 DCUs fitted with the WCS. The presence of biofilm in DUWs was examined by electron microscopy.

RESULTS

During the first 9 months a high prevalence (28/300 disinfection cycles; 9.3%) of intermittent DUW disinfection failure occurred in 8/10 DCUs due to operator omission to disinfect all DUWs (10/28 failed cycles), incorrect compressed air pressure failing to distribute the disinfectant properly (4/28 failed cycles) and physical blockage of disinfectant intake valves due to corrosion effects of Planosil (14/28 failed cycles). On rectification of these faults through engineering redesign and procedural changes, no further cases of intermittent DUW disinfection failure were observed. Independently of these factors, a rapid and consistent decline in efficacy of DUW disinfection occurred in 4/10 DCUs following the initial 9 months of once weekly disinfection. There was a highly significant difference (P<0.0001) in the prevalence of strongly catalase-positive Novosphingobium and Sphingomonas bacterial species (mean average prevalence of 37.1%) in DUW output water from these 4 DCUs compared to the other 6 DCUs and DCU supply water (prevalence <1%), which correlated with biofilm presence in the DUWs and indicated selective pressure for maintenance of these species by prolonged disinfectant usage. Planosil was reformulated to a more concentrated form (Planosil Forte) and when used once weekly was found to maintain bacterial density in output water below the ADA standard for all 10 DCUs.

CONCLUSIONS

A variety of factors can contribute to failure of DUW disinfection in the long-term, including human error, disinfectant corrosion of equipment and natural selection of naturally disinfectant-tolerant bacterial species.

The presence of Pseudomonas aeruginosa in the dental unit waterline systems of teaching clinics

OBJECTIVE

The objective of this study was to evaluate the extent of Pseudomonas aeruginosa contamination of Dental Unit Water (DUW) at a Dental Teaching Center in Jordan.

METHODS

Water samples were collected from 30 dental units, 10 from each of three teaching clinics, namely conservative dentistry, periodontology, and prosthodontics. Samples were collected from the outlet of the air/water syringe, high-speed handpiece and water cup filler, at the beginning of the working day (before use), after 2 min flushing, and at midday.

RESULTS

P. aeruginosa was detected in 86.7% (26/30) of the dental units at the beginning of the working day, and in 73.3% (22/30) after 2 min of flushing and at midday. Conservative dentistry units had the highest counts, followed by periodontology and prosthodontics (P<0.05). Overall, the highest counts (log10 count CFU ml-1) were at the beginning of the working day (1.38+/-1.05), and the lowest counts after flushing for 2 min (1.10+/-1.03), and higher numbers were seen again at midday (1.15+/-1.04) (P<0.05).

CONCLUSIONS

86.7% of the dental units were contaminated with P. aeruginosa, the conservative dentistry units had the highest amount of contamination. Flushing the DUW for 2 min significantly reduced the counts of P. aeruginosa.

Attitudes of general dental practitioners in Europe to the microbial risk associated with dental unit water systems

Dental Unit Water Systems (DUWS) are used in dental practices to provide water for cooling of dental equipment and irrigation of the oral cavity. However, they have been demonstrated to be contaminated with micro-organisms. There are currently no European Union (EU) Commission guidelines for the microbial quality of water discharged by DUWS. This study was part of an EU research programme to investigate the microbial contamination of DUWS in general dental practice (GDP) in the UK, Denmark, Germany, The Netherlands, Ireland, Greece and Spain.

OBJECTIVE

To undertake a questionnaire survey on the type of DUWS in use and determine the attitude of GDPs to the risk of microbial infection from DUWS.

MATERIALS AND METHODS

The questionnaire was written and translated into the language of each country before being posted to each participating dentist. Dentists were asked to complete the questionnaire survey and return it by post.

RESULTS AND CONCLUSIONS

The major findings were that the majority of dentists did not clean, disinfect or determine the microbial load of their DUWS, and that dentists would welcome regular monitoring and advice on maintaining their DUWS; the introduction of guidelines; and recommendations on controlling the microbial load of DUWS.