In this interview with Dentistry Today, HuFriedyGroup experts explain why dental practices need to ensure they are properly maintaining their DUWLs.
By Stan Goff, Senior Managing Editor
Dental unit waterlines (DUWLs) are crucial for cooling and irrigating during dental procedures, but they can also harbor bacterial growth due to their small size and the potential for stagnation. While dental practices are aware that maintaining clean DUWLs is essential for patient safety and require regular cleaning, disinfection, and monitoring, some may not be aware of the best options available to them, and others may encounter barriers when it comes to implementing the best practices.
HuFriedyGroup, which manufacturers a variety of infection control products including the DentaPure Independent Water Bottle Cartridge DentaPure DP365B, addresses the importance of consistent dental unit waterline infection control practices and explains the benefits of products that ensure that practices are doing all they can to protect patients and the staff.
Q: Why is staying on top of DUWLs so important?
A: Maintaining DUWLs is essential to protecting patients and dental staff from exposure to harmful bacteria during treatment.
Bacteria from sources like the patient’s mouth or municipal water supply can adhere to the interior surface of these narrow (~2mm) and spaghetti-like waterlines, forming a slimy protective layer of biofilm. If not routinely treated with a germicidal waterline maintenance product, the biofilm will continue to feed and multiply. Once established, biofilm is extremely difficult to remove, and standard dental waterline maintenance products are no longer effective in ensuring procedural water is compliant with potable water standards. At that point, a waterline shock treatment – “the big gun” – is needed to remove the biofilm.
Q: Have there been any major developments in the treatment of DUWLs in recent years and how are practices kept up to date on the best methods for ensuring they’re keeping the practice’s water clean?
A: In recent years, outbreaks linked to contaminated dental waterlines – specifically in pediatric dental offices where patients had pulpotomies (baby root canals) that expose the pulp of the tooth, have brought increased attention to waterline safety and management. Despite coverage by major news outlets, a persistent and dangerous misconception remains within part of the dental community “our office does not treat pediatric patients, so we are not at risk.”
This mindset overlooks a critical fact that vulnerable patients such as children, the elderly, immunocompromised and even dental staff are all at risk for exposure to contaminated dental waterlines. The absence of widely reported outbreaks in adult populations contributes to a false sense of security.
In actuality, illnesses related to contaminated dental water exposure, like respiratory infections, often go unlinked to dental visits. Why? A patient would likely visit their primary care physician when they are feeling ill and that physician most likely would not ask about recent dental treatment. This presents a missed opportunity for identifying the real source of infection.
Until recently, there was only “guidance” from bodies like the Centers for Disease Control and Prevention (CDC) that spoke to the need to test and maintain DUWLs, but provided no statement on frequency. CDC guidance is required to be followed in many states, and as guidance only, it leaves much open to interpretation
However, many states are taking notice. Starting with California in 2017 making it a law to utilize sterile solutions during dental treatments that expose dental pulp. Both WA state and GA have enacted laws requiring quarterly dental waterline testing. More are sure to follow.
Dental offices should look to their state dental board, CDC, ADA, and ADS for continued water management guidance.
From an industry standpoint, there has been a shift over the years from the use of waterline maintenance tablets which require staff to remember to place the tablet in the water bottle on the dental unit with every water change/wait for it to dissolve, to continuous waterline maintenance products – cartridges/straws (like the HuFriedyGroup DentaPure cartridge) that are placed directly on the unit’s pickup tube and replaced once or twice a year. Continuous maintenance products generally require fewer protocols, potentially reducing human error.
Q: Is water treatment something that too many practices overlook or take for granted?
A: I don’t believe that practices take water treatment for granted, I think it’s more that offices believe that the “good” water that they are using is appropriate for patient treatment. Outside of sterile water that must be used for surgical procedures, an office that uses distilled, RO or filtered water that either comes into the building, or through a specialized filtration system more than likely does not realize that when it comes to DUWLs, putting good in does not mean getting good out. Water that starts out as potable can quickly become contaminated once inside the waterlines if it is not treated with germicide.
Q: What are the benefits of the DentaPure Cartridge? Please elaborate on how it works.
A: DentaPure cartridges contain iodinated resin beads. During a typical treatment, the resin beads release 2 to 6ppm of elemental iodine into the water passing through the cartridges. The iodine interacts with the bacteria in the water, controlling it.
The DentaPure Cartridge is for use on dental unit waterlines attached to dynamic instruments. When used according to labeling, these cartridges reduce microbial contamination from the procedural water supplied through the instruments to provide water that meets current microbiological standards.
- Cartridges are available for bottle-based units and units plumbed directly to city water.
- One single cartridge maintains compliant procedural water for 365 days or 240L of water.
- When compared to other waterline maintenance treatments, a cartridge like DentaPure may reduce the possibility of human error due to fewer protocol requirements.
- DentaPure cartridges do not interfere with dental materials and bonding and cause no corrosion or etching.
What about patients with iodine allergies?
Elemental iodine as found in the DentaPure Cartridge is not known to cause sensitivity reactions. No patient safety warnings are present in the product Instructions for Use.
Elemental iodine contains no allergenic proteins. Patients are not allergic to iodine; they are allergic to the protein sometimes attached to it (Schabelman E1, Witting M. The relationship of radiocontrast, iodine, and seafood allergies: a medical myth exposed, J Emerg Med. 2010 Nov;39(5):701-7. doi: 10.1016/5).
At typical elution rates, the amount of iodine that a patient would be exposed to during a typical dental visit is far exceeded by the standard servings of many common foods such as 1C of milk, a large egg, a slice of bread (cc.nih.gov/ccc/patient_education/pepubs/lo_io_diet.pdf).
Q: Is the system easy to use and is there much of a learning curve?
A: The DentaPure Cartridge for bottle-based units is incredibly easy to install and use.
Installation:
- Remove the dental unit’s water bottle to reveal the bottle pick-up tube
- Align the bottle alongside the pick-up tube to ensure that the cartridge can be attached to the tube with enough space to fit inside the bottle while leaving ¼” to ½” of space from the bottom of the bottle
- Once measured, cut the pick-up tube and securely insert the included plastic fitting into the cut end of the tubing
- Remove the protective dust caps and attach the tip of the cartridge to the plastic fitting with a simple twist
Protocols following installation are simple:
- Perform a total 2-minute flush of all lines connected to water on the unit at the start of each day that the office is open to ensure that iodine is flowing through the system
- Perform hygienic procedures: wash and fill the bottle with fresh water each morning
- Follow best practice infection control by:
- Adhering to CDC/ADA guideline for aseptic procedure including a 20- to 30-second flush of water and air after each patient, from any device connected to the dental water systems that enters a patient’s mouth
- Continuing handpiece sterilization
- Wiping down the cartridge if using a bottle that does not provide a protective enclosure that inhibits daily cartridge wiping
Q: Water seems to be in the news a lot lately. Explain why this creates a great opportunity for dental practices to make sure they are properly treating and testing and is this something they can use to build confidence with patients who may have questions or concerns?
A: Becoming aware of an issue that the office did not know is always a tricky learning process. The important next step for the office would be to create a protocol or change a current protocol to include the proper steps in regard to this new information. This may require some research by the office or consulting external experts.
Q: Explain how a consistent protocol benefits both patients and staff.
A: A successful waterline maintenance protocol includes staff education, waterline testing, shocking and regular waterline maintenance to ensure that lines are at their best and ready for continued patient treatment and documentation/continued education.
It is important to acknowledge implementation consistency across multiple offices and to remember that every dental until tells its own story. No 2 are the same.
Establishing and following protocols is key to waterline compliance success:
- Preparation
- Research and select products for testing, shocking and maintenance with protocols that the office can consistently comply with
- Educate staff responsible for waterline maintenance on protocols prior to product implementation
- Implementation
Test
* Testing and monitoring are essential for dental offices to assess the compliance of their procedural water with current microbiological standards. Additionally, test results provide verification that waterline maintenance and shock protocols are being properly implemented.
* Test frequency should be based on:
- State/local guidance, Office protocols, Equipment manufacturer recommendations, Waterline maintenance product recommendations
- In the absence of guidance from any of the above, ADS (Association for Dental Safety – formerly OSAP) recommends testing monthly until 2 consecutive passing months and then switching to no less than quarterly
* The CDC and ADA both recommend waterline testing, but provide no specific guidance on frequency
Test methods include:
- Mail-in laboratory testing for a quantitative result to understand the exact measurement of CFU/mL (colony forming units per milliliter of water)
- In-office testing as a screening tool for a qualitative pass/fail result
- It is recommended to use these test methods in combination as part of a holistic protocol for waterline maintenance
Retesting following remediation with shock is important to ensure that the lines are clean and protocols properly followed
Utilizing an aseptic technique when preparing for and drawing samples for testing is critical to ensure the most accurate test results.
Shock
- Shocking is a periodic method of rapidly treating DUWLs to remove bacteria and biofilm and slow the regrowth of biofilm
- If you think about pool maintenance, chlorine is used to prevent pools from turning green by attacking and neutralizing harmful bacteria and microorganisms. However, sometimes, pools turn green even with chlorine use. Introducing a shock product as needed fixes the problem and allows a swift return to regular maintenance.
- Shock frequency
- An office should shock:
- Following waterline test failure, based on office protocol, equipment manufacturer instruction or waterline treatment product instructions
Maintain
- Implement use of a regular waterline maintenance product like the DentaPure cartridge to ensure that chairs are compliant and “patient ready”
- Continuation
- Document
- Maintain consistent documentation
- Testing: Dates/times, results, remediation for failure
- Waterline Maintenance
- Training
- Without documentation, it didn’t happen
- Maintain consistent documentation
- Continued Education
- Ensure staff is up-to-date on product protocols and re-train as necessary
- Set-up training
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- Who is being trained
- What are they being trained on
- Frequency
