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.

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.

Total viable counts, ATP, and endotoxin levels as potential markers of microbial contamination of dental unit water systems

OBJECTIVES

To determine if either ATP or endotoxin concentrations in water supplied by dental unit water systems (DUWS) correlated with total viable counts (TVC), and therefore could be used as a rapid, chairside measure of levels of microbial contamination.

DESIGN

A prospective trial.

METHOD

Fifty-seven water samples were taken from the 'triple spray', air rotor and source water supplies from 25 dental units in eight practices. The samples were assayed for endotoxin concentration, total ATP and TVC. A pilot study was performed to assess the relationship between TVC and total cell counts, as determined by flow cytometry.

RESULTS

ATP concentrations ranged from 22 to 958 relative light units (RLU) and free endotoxin ranged from 25 to 600 EU ml(-1). TVC varied from not detected to 2.16 x 10(4) CFU ml(-1). The ATP method proved to be a simple and rapid method that could be used at the chairside. However, there was no correlation between ATP or endotoxin concentrations and TVC in DUWS. TVC generally underestimated the total cell count by 50 to 500 fold.

CONCLUSION

Half of the water samples from DUWS exceeded recommended levels of TVC. However, ATP and endotoxin concentrations in DUWS water samples did not correlate with these TVC data and therefore could not be recommended as an alternative assay to TVC for measuring bacterial contamination or for monitoring water treatment efficacy.

Decontamination of tried-in orthodontic molar bands

Molar bands are commonly used to retain orthodontic attachments on posterior teeth and due to the variation in the size of such teeth, it is usually necessary to 'try in' several bands before the correct one is selected. A possible concern with re-using such bands is the lack of cross-infection control, even following autoclaving, due to the presence of one or more small bore lumen (the archwire and headgear tubes). The aim of this experiment was, therefore, to determine whether such bands could be successfully decontaminated so that they could be re-used without a cross-infection risk. Two hundred orthodontic molar bands that had previously been tried in patients' mouths, but not cemented into place, were tested. Each band was decontaminated using an enzymatic cleaner/disinfectant and then sterilized using either a downward displacement (n = 100) or a vacuum cycle autoclave (n = 100). Following autoclaving each band was inoculated into brain heart infusion culture broth and incubated at 37 degrees C for 5 days. None of the decontaminated bands exhibited growth after 5 days. It would appear that, using this methodology, there is little risk of a cross-infection hazard occurring with the re-use of previously tried-in and decontaminated molar bands.

Microbiological evaluation of a range of disinfectant products to control mixed-species biofilm contamination in a laboratory model of a dental unit water system

Dental unit water system (DUWS) tubing harbors complex multispecies biofilms that are responsible for high microbial levels at the distal outlet. The aim of this study was to use an established biofilm laboratory model to simulate biofouling of DUWS to evaluate practical, cost-effective, and evidence-based methods of microbial decontamination. Reproducible biofilms were developed in the model over 14 days; decontamination was assessed using total viable counts (TVC) and microscopic-image analysis techniques to view the inner surface of tubing. Flushing did not reduce the biofilm coverage or TVC. Combizyme and ozone did not completely eliminate the viable bacteria (70 and 65% reduction in biofilm TVC, respectively), nor did they remove the biofilm (45 and 57% reduction in biofilm coverage, respectively). Chlorhexidine and Bio2000 (active agent: ethanol and chlorhexidine), Tegodor and Gigasept Rapid (aldehyde based), and Grotanol (hydroxide based) completely eliminated the TVC but did not completely remove biofilm (31, 53 33, 34, and 64.9% reduction of biofilm coverage, respectively). Other products including Grotanol Flussig (phenol based), Betadine (povidone-iodine based), Alpron (chlorite based), and the hydroxide-containing products Sporklenz, Sterilex Ultra, Dialox, Sterilox, Sanosil, Oxigenal, and Grotanat Bohrerbad resulted in a 100% reduction in the biofilm TVC and a >95% reduction in biofilm coverage. The study demonstrated that while many disinfectants achieve a sufficient reduction in TVC they may not necessarily remove unwanted biofilm from the tubing surfaces as tested in this laboratory-controlled biofilm model.

Microbial aerosols in general dental practice

OBJECTIVE

To measure the concentration of microbial aerosols in general dental practices and to use this information to carry out quantitative microbiological risk assessments.

METHODOLOGY

Microbial air sampling was carried out continuously during 12 treatment sessions in 6 general dental practices in the South West of England.

RESULTS

The microbial aerosol concentration in treatment rooms was generally less than 10(3) colony forming units per cubic metre of air (cfu x m(-3)). However, in 6 out of the 12 visits, at least one peak concentration with much higher numbers of bacteria was detected. The peak concentrations were associated with increased recoveries of presumptive oral streptococci suggesting these aerosols originated from the mouths of patients. These aerosol peaks dissipated within 30 minutes and no dissemination into waiting areas was detected. The peak concentrations were associated with mechanical scaling procedures (47% of procedures giving rise to a peak) and to a lesser extent by cavity preparation (11%). No aerosolised blood was detected.

CONCLUSIONS

The data have been used to generate a framework for quantifying risk of exposure of staff to aerosolised microbial pathogens in general dental practice. For example, dentists and their assistants may have a slightly higher risk of exposure to Mycobacterium tuberculosis than the general public. The use of face seal masks that have been shown to protect against aerosolised micro-organisms may reduce this exposure.

Microbial biofilm formation and contamination of dental-unit water systems in general dental practice

Dental-unit water systems (DUWS) harbor bacterial biofilms, which may serve as a haven for pathogens. The aim of this study was to investigate the microbial load of water from DUWS in general dental practices and the biofouling of DUWS tubing. Water and tube samples were taken from 55 dental surgeries in southwestern England. Contamination was determined by viable counts on environmentally selective, clinically selective, and pathogen-selective media, and biofouling was determined by using microscopic and image analysis techniques. Microbial loading ranged from 500 to 10(5) CFU. ml(-1); in 95% of DUWS water samples, it exceeded European Union drinking water guidelines and in 83% it exceeded American Dental Association DUWS standards. Among visible bacteria, 68% were viable by BacLight staining, but only 5% of this "viable by BacLight" fraction produced colonies on agar plates. Legionella pneumophila, Mycobacterium spp., Candida spp., and Pseudomonas spp. were detected in one, five, two, and nine different surgeries, respectively. Presumptive oral streptococci and Fusobacterium spp. were detected in four and one surgeries, respectively, suggesting back siphonage and failure of antiretraction devices. Hepatitis B virus was never detected. Decontamination strategies (5 of 55 surgeries) significantly reduced biofilm coverage but significantly increased microbial numbers in the water phase (in both cases, P < 0.05). Microbial loads were not significantly different in DUWS fed with soft, hard, deionized, or distilled water or in different DUWS (main, tank, or bottle fed). Microbiologically, no DUWS can be considered "cleaner" than others. DUWS deliver water to patients with microbial levels exceeding those considered safe for drinking water.

Roxithromycin as a possible agent for prophylaxis of endocarditis: a study in normal volunteers

A single dose of roxithromycin, 300 mg, was taken by six healthy male volunteers on three occasions at consecutive weekly intervals. It was well tolerated. On the first two occasions, roxithromycin was assayed in serum samples taken at intervals up to 8 h after the administration. The mean peak concentration at 1 h was 3.0 mg/l (range 0.3-7.3). The serum samples from the volunteers showed variable bactericidal activity against a strain of Streptococcus sanguis isolated from a case of bacterial endocarditis. Roxithromycin was not detected in saliva or gingival fluid. Smooth surface plaque samples taken at intervals were investigated for the emergence of streptococci resistant to roxithromycin at 2 and 8 mg/l. Initially two volunteers had small number of roxithromycin-resistant streptococci. At the end of the study all six volunteers had resistant streptococci detectable in their plaque samples and these accounted for 100% of the streptococci in two volunteers. The most resistant isolates (in several cases with MIC greater than 64 mg/l) were Str. sanguis or Str. mitior; individual volunteers tended to yield the same strain on consecutive samplings.