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.

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

Water delivered by dental unit water systems (DUWS) in general dental practices can harbor high numbers of bacteria, including opportunistic pathogens. Biofilms on tubing within DUWS provide a reservoir for microorganisms and should be controlled. This study compared disinfection products for their ability to meet the American Dental Association's guideline of <200 CFU x ml(-1) for DUWS water. Alpron, BioBlue, Dentosept, Oxygenal, Sanosil, Sterilex Ultra, and Ster4Spray were tested in DUWS (n = 134) in Denmark, Germany, Greece, Ireland, The Netherlands, Spain, and the United Kingdom. Weekly water samples were tested for total viable counts (TVCs) on yeast extract agar, and, where possible, the effects of products on established biofilm (TVCs) were measured. A 4- to 5-week baseline measurement period was followed by 6 to 8 weeks of disinfection (intermittent or continuous product application). DUWS water TVCs before disinfection ranged from 0 to 5.41 log CFU x ml(-1). Disinfectants achieved reductions in the median water TVC ranging from 0.69 (Ster4Spray) to 3.11 (Dentosept) log CFU x ml(-1), although occasional high values (up to 4.88 log CFU x ml(-1)) occurred with all products. Before treatment, 64% of all baseline samples exceeded American Dental Association guidelines, compared to only 17% following commencement of treatment; where tested, biofilm TVCs were reduced to below detectable levels. The antimicrobial efficacies of products varied (e.g., 91% of water samples from DUWS treated with Dentosept or Oxygenal met American Dental Association guidelines, compared to 60% of those treated with Ster4Spray). Overall, the continuously applied products performed better than those applied intermittently. The most effective products were Dentosept and Oxygenal, although Dentosept gave the most consistent and sustained antimicrobial effect over time.

Antiviral activity of alcohol for surface disinfection

Bacteria and viruses from the patient's mouth travel with dental splatter and spills. A surface disinfectant should possess antiviral activity as well as antibacterial action. Because of frequent and 'open' application in the dental office, such a disinfectant should be non-toxic, non-allergenic and safe for the hygienist. It now appears that high-concentration alcohol mixtures (i.e. 80% ethanol + 5% isopropanol) are not only excellent antibacterials, but quickly inactivate HIV as well as hepatitis B and hepatitis C viruses. Compared to alternative surface disinfectants, use of high-concentration alcohol for the spray-wipe-spray method of surface disinfection in dentistry appears safe and efficient. However, dried matter should be wiped and hydrated first.

Total and Free Fluoride in Toothpastes from Some Non-Established Market Economy Countries

In 101 fluoride toothpastes, bought in local shops in Burkina Faso (n = 3), China (n = 5), Myanmar (n = 22), Nepal (n = 19), Philippines (n = 13), Syria (n = 22), Togo (n = 7) and Vietnam (n = 10), the total and free ionisable fluoride concentrations were established. The total fluoride concentration of the toothpastes was determined by gas liquid chromatography. The amount of soluble fluoride was measured after dilution in artificial saliva and treatment of the supernatants with acidic phosphatase. The free fluoride concentration in this mixture was measured with a fluoride electrode. Twenty-five percent of all toothpastes contained less than 738 ppm total fluoride, and another 25% contained between 738 and 977 ppm fluoride. Regarding free ionisable fluoride the 25th, 50th, and 75th percentile contained < or =275, 780 and 990 ppm fluoride, respectively. Of the 61 toothpastes with declared fluoride concentration, 75% contained a total F concentration of > or =89% of the declared concentration. In 25% of these toothpastes the free ionisable fluoride was < or =55% of the declared fluoride, and in another 25% of the pastes the free ionisable fluoride concentration was > or =89% of the declared fluoride. In conclusion, deficiencies were found regarding the total as well as the free ionisable fluoride concentration of toothpastes bought in non-established market economy countries. Unclear labelling concerning the type and concentration of fluoride was often encountered. A need for quality control of fluoride toothpastes is recommended.

Microbiological evaluation of dental unit water systems in general dental practice in Europe

A range of opportunistic pathogens have been associated with dental unit water systems (DUWS), particularly in the biofilms that can line the tubing. This study therefore aimed to assess the microbiology of DUWS and biofilms in general dental practices across seven European countries, including the United Kingdom (UK), Ireland (IRL), Greece (GR), Spain (ES), Germany (D), Denmark (DK) and the Netherlands (NL). Water supplied by 51% of 237 dental unit water lines exceeded current American Dental Association recommendations of < or = 200 colony-forming units (CFU) ml(-1). Microbiological loading of the source waters was between 0 (Denmark, the Netherlands and Spain) and 4.67 (IRL) log CFU ml(-1); water line samples from the DUWS ranged from 1.52 (ES) to 2.79 (GR) log CFU ml(-1); and biofilm counts ranged from 1.49 (GR) to 3.22 (DK) log CFU.cm(-2). Opportunistic pathogens such as legionellae (DK and ES), including Legionella pneumophila SG1 (DK and GR), and Mycobacterium spp. (DK, NL, GR, D and ES) were recovered occasionally. Presumptive oral streptococci (ES and NL), oral anaerobes (GR), Candida spp. (UK, NL and ES) and blood (GR and IRL) were detected at relatively low frequencies, but their presence indicated a failure of the 3-in-1 antiretraction valve, leading to back siphonage of oral fluids into the water and biofilm phase. These findings confirm that a substantial proportion of DUWS have high levels of microbial contamination, irrespective of country, type of equipment and source water. The study emphasizes the need for effective mechanisms to reduce the microbial burden within DUWS, and highlights the risk of occupational exposure and cross-infection in general dental practice.

[Solvents for the removal of gutta-percha from root canals. 2. Side effects of chloroform, halothane and xylene]

High concentrations of organic solvents have adverse effects on the health of professional workers. In endodontics, halothane, chloroform and xylene are used to dissolve gutta-percha from root canals. It is therefore questioned whether the use of these solvents could affect the health of patients or of the dental team. It seems warranted to conclude that the amounts and concentrations of chloroform, xylene and halothane such as used in endodontic retreatment, are low and therefore are safe. However, the dentist should be aware of possible hypersensitivity induced by previous application of halothane as a narcotic.

[Solvents for the removal of gutta-percha from root canals. 1. Efficacy]

The removal of gutta-percha and sealer from endodontically treated root canals may prompt the use of organic solvents. In the present article a number of possible solvents are described and, based upon the literature, their efficacy is assessed. Some solvents, amongst which chloroform, xylene and halothane are almost equally efficient, although all leave a debris of gutta-percha and sealer in the root canals behind. Only chloroform solves AH26 and most probably AH-plus, but very slowly. Eucalyptol and turpentine oil are slow dissolvers. Orange oil and limonene are promising. The data on other solvents, if candidates at all, are scarce. The choice of a solvent is co-determined by factors such as toxicity and sensitisation, which will be described in a second publication.

[Prevention of viral cross-infection. Surface disinfection with 80% ethanol]

High concentrations (80-90%) of ethanol seem to be best for use in the dental office. A mixture of 80% ethanol and 5% isopropanol was shown to inactivate HIV, hepatitis B and C viruses within 20 seconds. Compared with alternative antiviral disinfectants, such a mixture is non allergenic and minimally toxic for the dental team. It is suitable for spraying or for the spray-wipe-spray technique as an important cross-infection control measure in dentistry.

[110th year Nederlands Tijdschrift voor Tandheelkunde. 2. Root canal treatment, intra-canal disinfectants and bacterial culture: past and present]

Fifty years ago the Dutch Journal of Dentistry published methods and opinions concerning root canal treatment. Qualitative bacterial culture, inclusion of aggressive disinfectants, as well as antibiotics and widening of the apical constriction were carried out. Nowadays, because of several reasons, these are not clinical practice anymore. Controversy over the clinical consequences of bacterial presence in tubules and in the peri-apical area prevailed in the past and seem to be prevalent once again.

The virucidal spectrum of a high concentration alcohol mixture

The virucidal spectrum of a high concentration alcohol mixture (80% ethanol and 5% isopropanol) was determined for a broad series of lipid-enveloped (LE) and non-lipid-enveloped (NLE) viruses covering all relevant blood-borne viruses. LE viruses were represented by human immunodeficiency virus (HIV), bovine viral diarrhoea virus (BVDV), a specific model virus for hepatitis C virus (HCV), pseudorabies virus (PRV), and vaccinia virus. For the NLE viruses hepatitis A virus, canine parvovirus (a model for human parvovirus B19), and reovirus type 3 (Reo-3) were used. PRV, vaccinia, and Reo-3 served as general model viruses. The alcohol mixture was spiked with 5% (v/v) virus, mixed and tested for residual virus after 5 min treatment. Complete clearance (reduction by a factor of >10(6)) was observed for LE viruses, whereas incomplete to insignificant clearance (ranging from no reduction up to a maximum factor of 10(4)) was found for NLE viruses. In a second series of spiking experiments using the LE viruses BVDV, HIV, and PRV, complete clearance (reduction by a factor of >10(6)) was found after 20 s treatment. These data strongly suggest that treatment with a high concentration alcohol mixture has a high virucidal potential in particular for the blood-borne LE-viruses HIV, hepatitis B virus, and HCV. Such mixtures are well suited for rapid and frequent disinfection in dental practice being non-hazardous and non-toxic.

[Hormone dysregulators. Pseudo-estrogens in dental composite resins and sealanta?]

A number of polluting chemicals in the ecosystems must be characterized as hormone disruptors. Among others, male animals appear to become feminized by the action of the so-called pseudo-estrogens and under their influence mens' fertility is said to decrease. Composites and sealants based on Bis-GMA resin may contain bisphenol-A as an impurity and Bis-DMA, from which in saliva bisphenol-A will be formed by hydrolytic degradation. Therefore, in extreme circumstances a weak estrogenic effect is not impossible on the short-term. However, the amounts of these probably not very potent estrogenic compounds are small, thereby resulting in a tolerable risk on the short term. Long-term-effects and synergism with pseudo-estrogens from other sources prompt further studies in order to verify the safety of the Bis-GMA containing products.

Penetration of bacteria in bovine root dentine in vitro

AIM

The aim of this study was to develop a test model to quantify the penetration of bacteria into dentinal tubules.

METHODOLOGY

The model consisted of two compartments separated by a bovine dentine specimen with a thickness of 1.5-3.1 mm. The root cementum was removed from the root surface and the specimens were oriented in the model with the pulpal side facing the inoculated chamber of the test model. One compartment contained the test organism and the other was filled with sterile broth that was evaluated for growth of the test organism. The depth of bacterial penetration was measured in the dentine with or without a smear layer using both a histological and a quantitative recovering grinding technique, after 6 weeks of exposure to the microorganisms.

RESULTS

E. faecalis penetrated dentine significantly deeper than A. israelii (P < 0.001). After removal of the smear layer with EDTA, E. faecalis penetrated significantly deeper than in dentine pretreated with saline only (P < 0.01) or with a combination of saline and sodium hypochlorite (P < 0.01). Microorganisms were found in 89% of the cultured specimens and in 80% of the specimens that were evaluated with light microscopy. Total penetration through the dentine specimen and infection of the broth in the test compartment of the model occurred in only two out of 72 specimens.

CONCLUSION

Collection and immediate culturing of infected dentine dust and counting colony forming units (CFU) allowed an overview of the number of bacteria per sample and was more sensitive than microscopy. Removal of the smear layer enhanced bacterial penetration.

The fate and the role of bacteria left in root dentinal tubules

In this article the question of the relevance and consequences of bacteria remaining in the tubules of root dentine after cleaning and shaping of the root canal space is addressed. A second aim is to discuss the necessity of clinical measures taken to eradicate those bacteria that are presumed to survive there. The available clinical and experimental evidence supports the use of antibacterial dressings in cases where the root canal space remains temporarily unobturated after removal of necrotic and infected pulp tissue. There is no evidence, however, that special measures should be taken to kill the bacteria in the dentinal tubules. Should time permit, a sound obturation technique immediately following the cleaning, shaping and disinfection phases allows the remaining bacteria in the tubules to be either inactivated or prevented from repopulating the (former) canal space. In the vast majority of cases, those bacteria appear not to jeopardize the successful outcome of root canal treatment.

[HIV and dentistry. Part 5. Practice hygiene]

When complying a good standard hygiene protocol in the dental office the risk of cross-infection of whatever type of microorganism, including the hepatitis-B-virus and HIV, is almost eliminated.

Fluid transport and bacterial penetration along root canal fillings

Convective transport of water from the coronal to the apical end of obturated root canals was determined by the movement of an air bubble in a capillary glass tube connected to the apex of the experimental root section using a headspace pressure of 120 kPa (1.2 atm). Water transport through existing voids in the obturated canals could be measured reproducibly in this way. The root canals of 60 human maxillary canines were filled with gutta-percha and sealer by the cold lateral condensation technique. Thirty of these were first exposed to a small motile bacterium, Pseudomonas aeruginosa, growing in a reservoir at the coronal end of each root. After 50 days, two specimens allowed penetration of bacteria to a reservoir at the apical end. All the roots were then assessed quantitatively for convective transport of water. The results were divided into three defined categories: 39 obturated canals were in the 'bacteria tight' category, 14 canals in the 'slight leakage' and 7 canals in the 'gross leakage' category. The two specimens that showed bacterial penetration fell into the slight and gross leakage categories. The previous test for bacterial passage did not statistically influence the fluid transport pattern of these roots which was measured subsequently. These findings indicate that fluids transport through obturated root canals, most of which do not allow the passage of bacteria.

Calcification of a cariogenic Streptococcus and of Corynebacterium (Bacterionema) matruchotii

The main aim of this investigation was to challenge the idea that cariogenic streptococci do not calcify. Calcium uptake of calcification of Streptococcus mutans C180-2, proven to be an acidogenic and cariogenic strain, was compared with calcium uptake and calcification of Corynebacterium (Bacterionema) matruchotii, known as a ready calcifier. Bacteria were grown on Brain Heart Infusion Agar (BHIA) and on well-buffered semi-synthetic E-agar, both containing 1.4 mmol/L calcium, 2 g/L glucose, initial pH 7.4. Calcium uptake from BHIA by C. matruchotii (25 mmol Ca/kg wet bacterial cell mass), but not by S. mutans, was found. Grown as a plaque-like lawn on E-agar, the S. mutans cell mass concentrated calcium to 63 +/- 11 mmol/kg compared with 145 +/- 61 mmol/kg in C. matruchotii. X-ray diffraction confirmed the presence of crystalline apatite in the bacterial cell masses. Electron microscopy revealed crystals and mineralized deposits in both organisms. Heavy calcifications in some cells of S. mutans were seen. Calcification was partly inhibited by magnesium ion and by methanehydroxybisphosphonate. S. sobrinus 6715, as well as freshly isolated S. mutans and S. sobrinus from patients, concentrated very large quantities of calcium, up to 500-fold from the medium, when maintained for several weeks on E-agar of initial pH 7.6. Our observations widen the view on acidogenic bacteria as mineralization agents and support the notion that members of the mutans group of streptococci may be involved in events that trigger heavy intracellular calcifications and, possibly, dental calculus formation.

[Recommended protection against infection in the dental office]

Identification of pathways of microbial contamination and assessment of corresponding infection risks in general dental practice, precede the recommendation of infection control activities. Ten practical and appropriate rules are suggested.

Capacity of anaerobic bacteria enclosed in a simulated root canal to induce inflammation

In an effort to simulate the infected dental root canal, bacteria were enclosed in polyethylene tubes that were subcutaneously implanted into rats. Four different bacterial combinations, selected from nine oral species, were tested. The contents of 144 inoculated and implanted 'root canals' were analysed after 2 and 4 weeks of implantation. Bacteroides, Streptococcus, Actinomyces and Fusobacterium were inoculated in low numbers but dominated the mixed flora at the end of the experiment. The bacteria-filled tubes induced inflammation of the rat tissue at the implant opening ('foramen'). It is confirmed that mixed bacterial populations survive, show succession and develop within an enclosed environment. Such florae cause significant inflammation at the interface with the host tissues.

[Pain, flare-ups and failures in root canal therapy]

In this overview the incidences and causes of pain, flare-ups and failures that occur after root canal therapy are discussed. Infection is considered the most important single, underlying determinant of the many factors that may cause pain and failures. Therefore, strict adherence to recognized therapeutic principles of shaping, disinfection and filling, in addition to proper aftercare, is of importance to diminish postoperative sequelae.

Particles and molecules in endodontic leakage

It is assumed that above a critical level, microleakage causes periapical disease and jeopardizes periapical tissue repair. The purpose of this investigation was first to find out to what degree obturation prevents leakage of bacteria-sized particles or large protein molecules, and second if leakage of the commonly used dye methylene blue is comparable with that of a small bacterial metabolic product of similar molecular size. Sections, 9 mm long, obtained from 46 extracted human incisor roots had their root canals prepared in a standardized manner and obturated in four experimental ways using gutta-percha. The root sections were mounted in the middle of tubes that were closed at both ends with rubber membrane stoppers, which permitted sampling from the apical reservoir. The coronal reservoir was filled with a solution of 1 mg/ml latex beads, 4 micrograms/ml endotoxin, 0.5 per cent butyric acid, 0.1 per cent valeric acid and 0.1 per cent methylene blue water. After 1 and 2 weeks, samples were taken from the apical reservoir and tested for the presence of latex beads by phase-contrast microscopy, for endotoxin with a limulus lysate test, for butyric acid with gas-chromatography and for methylene blue with spectrophotometric analysis. Leakage of bacteria-sized particles and large-sized protein molecules could be prevented only when both sealer and pressure were used in obturating root canals with gutta-percha. Leakage of butyric acid proved to be comparable with leakage of methylene blue; microleakage of these small molecules could not be prevented in this study whatever method of filling was used.

Bleeding/plaque ratio and the development of gingival inflammation

In a recent publication, it was hypothesized that the ratio between bleeding and plaque scores may act as a prognostic indicator for periodontal breakdown. Furthermore, it was found that the rate of development of gingival inflammation in terms of bleeding on probing during experimental gingivitis is more rapid in patients susceptible to periodontal breakdown than in subjects insusceptible to periodontal breakdown. The purpose of the present investigation was to compare the gingival reaction to dental plaque in an experimental gingivitis study in individuals without periodontal breakdown, having either a low or a high bleeding/plaque ratio. A group of 8 volunteers (18-23 years) with a low bleeding/plaque ratio and 7 volunteers (19-22 years) with a high bleeding/plaque ratio were selected. In both groups, an experimental gingivitis study of 23 days duration was carried out. Results showed that individuals with a high bleeding/plaque ratio developed significantly more clinical inflammation in terms of bleeding and swelling of the gingiva than individuals with a low bleeding/plaque ratio. After 23 days of plaque accumulation, gingival biopsies as well as supragingival plaque samples were taken from both groups. Phase-contrast microscopy of the plaque samples showed no significant differences between the 2 groups. Low %s of spirochetes and motile rods were found. Stereologic point-counting procedures showed equal amounts of infiltrated connective tissue in both groups. However, significant differences in composition of the infiltrate appeared to be present. The high ratio group showed more IgA producing plasma cells and complement activation than the low ratio group.(ABSTRACT TRUNCATED AT 250 WORDS)

Experimental gingivitis in relation to susceptibility to periodontal disease. II. Phase-contrast microbiological features and some host-response observations

In the present investigation, a number of histological and immunohistochemical characteristics of periodontal tissues as well as the phase-contrast microscopy of dental plaque were studied after experimentally-induced gingival inflammation in relation to susceptibility to periodontal disease. The study included a younger (mean age 34.1 years) and an older age group (mean age 48 years) with a reduced but healthy periodontium. Both age groups had the same amount of loss of attachment which may suggest that they had different degrees of susceptibility to periodontal disease. At the start of the experiment, each patient was instructed to abstain from oral hygiene in one quadrant of the mouth for a period of 18 days. At the end of the 18-day period, supra-gingival plaque and gingival tissue samples were taken. As determined by phase-contrast microscopy, the plaque samples of both age groups contained relatively high proportions of spirochetes. This may indicate that the patients are at risk for recurrence of periodontal breakdown. The general histopathologic picture of the gingival tissue samples of both age groups was similar to the so-called 'early lesion'. However, IgA-producing plasma cells were found in most tissue samples of both age groups. The first part of this study showed that the younger, in comparison to the older, patients developed inflammation in terms of bleeding on probing more rapidly. These clinical results cannot be explained by the host-parasite parameters investigated in the present study.

Abscess formation induced in rabbits with bacteria-filled subcutaneous implants that simulate the infected dental root canal

Short-term and semi-long-term tissue reactions to a mixture of "endodontopathic" bacteria are described. The bacteria are enclosed in experimental implant tubes simulating some aspects of the infected dental pulp. Localized abscesses develop in response to mixed bacterial contents of the implants. No abscess formation occurred with pure cultures (that is, either component of the mixture). Pathogenic inocula attract leukocytes to the adjacent tissues, which become inflamed and cause influx of leukocytes into the lumen of the implant proper.

Plaque and systemic disease: a reappraisal of the focal infection concept

The review presented here covers metastatic local and systemic disease secondary to the accumulation of plaque or the formation of other pathogenic microbial depots in the mouth. At least 3 pathways may link oral infection to secondary disease, to wit metastatic infection due to transient bacteremia, metastatic immunological injury, and metastatic toxic injury. The available evidence is presented and examples are provided. They concern among others such divergent diseases as acute bacterial myocarditis, infective endocarditis, brain abscess, uveitis and iridocyclitis, trigeminal and atypical facial neuralgia, unilateral facial paralysis, fever of "unknown' origin, and neutrophil dysfunction.

Antibacterial activity of gutta-percha cones attributed to the zinc oxide component

Growth of several species of bacteria was inhibited by the presence of endodontic gutta-percha cones. Microbiologic analysis, measurement of osmolarity, microscopy, x-ray diffraction analysis, and scanning electron micrography were used to identify the biologically active component that slowly leaches from gutta-percha cones. This component is zinc oxide in the form of small solid particles, from which active, soluble Zn2+ ion is mobilized by hydrolysis. A hypothesis on the "depot" effect of the ZnO particles is formulated, and is used to discuss some earlier reported literature on toxic and antibacterial activity of zinc oxide-containing materials. It is concluded that zinc oxide is not to be considered an inert compound. Its widespread uses in medicine and dentistry seem to reside in its "inert," biocompatible, and astringent properties mainly. The biologically active role of zinc oxide, however, merits further investigation.

Evidence for antibacterial activity of endodontic gutta-percha cones

In the presence of endodontic gutta-percha cones, several species of bacteria were killed in vitro. Silver points, when compared with gutta-percha cones, were not or were considerably less effective against the target organism. Staphylococcus aureus, in our assay system. Growth of bacteria in serum could be abolished by the mere presence of gutta-percha, especially when time was allowed for previous contact between the serum and the cones. It is concluded that gutta-percha cones possess a slowly acting, relatively weak, but, in our opinion, significant inherent antimicrobial property.

Thiocyanate as a cofactor in myeloperoxidase activity against Streptococcus mutans

Inhibition of glycolysis of some oral bacteria was established in vitro by an antibacterial system, consisting of myeloperoxidase, H2O2, and a cofactor. When thiocyanate was used in physiological concentration as a cofactor, the system acted (at low pH) bactericidally on Streptococcus mutans, as indicated by the determination of viable counts. However, at neutral pH, the glycolysis of Streptococcus mutans was inhibited, while its viability remained unaffected. The possible role of such a pH-dependent antibacterial system in the oral cavity is discussed.