Download Dental Unit Waterlines - R

A dental service man’s perspective
R-Tech Dental of MN, LLC
www.rtechdental.com
Michael Wiltrout, owner
800-826-8704
CDC
- For routine dental treatment, meet regulatory standards for drinking
water. <500 CFU/mL of heterotrophic water bacteria.
ADA
– "Encourages industry and the research community to improve the design
of dental equipment so that by the year 2000, water delivered to patients during
nonsurgical dental procedures consistently contains no more than 200 CFU/ml at
any point in the time in the unfiltered output of the dental unit."
EPA
- The number of bacteria in water used as a coolant/irrigant for nonsurgical
dental procedures should be as low as reasonably achievable and, at a minimum,
<500 CFU/mL
OSAP
- The regulatory standard for safe drinking water of <500 CFU/mL
APHA
(American Public Health Association) - the regulatory standard for safe
drinking water of <500 CFU/mL
AWWA
(American Water Works Association) - the regulatory standard for safe
drinking water of <500 CFU/mL
European
Union Drinking Water Standards specify a maximum of 100 CFU/mL
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Q. What are biofilms?
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Q. Will biofilms harm me?
◦ A. Biofilms are microscopic communities that consist primarily of naturally
occurring water bacteria and fungi. They form thin layers on virtually all
surfaces, including dental water delivery systems. These common
microbes or germs accumulate inside things like showerheads, faucets and
fountains, and in the thin tubes used to deliver water in dental treatment.
◦ A. Scientific reports have not linked illness to water passing through
dental waterlines. In our environment, we are exposed to countless germs
or bacteria. Yet, exposure to these common microbes does not mean that
an individual will get an infection or a disease. However, when a person’s
immune system is compromised because of age, smoking, heavy drinking,
being a transplant or cancer patient or because of HIV infection, he or she
may have more difficulty fighting off the invading germs. This is why the
ADA encourages patients who may have weakened immune systems to
inform their dentist at the beginning of any treatment. That way, the
patient and dentist together can make the right treatment decisions.
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Q. What has been done to prevent me from being exposed to
someone else’s saliva during dental treatment?
◦ A. The ADA recommends that dentists follow the infection control
guidelines of the ADA and CDC. These recommendations include the
sterilization of dental instruments and the flushing of waterlines between
patients. Additionally, the recommendations call for the installation and
maintenance of anti-retraction devices, where appropriate. All these
measures should help prevent exposure to someone else’s saliva.
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Q. What is the ADA goal for dental unit water?
◦ A. In 1995, the ADA set a goal for water quality. It called for equipment to
be available by the year 2000 that can provide unfiltered water with no
more than 200 CFU/ml (colony forming units per milliliter). That's the
same standard as for kidney dialysis machines, and it's a goal that
manufacturers are working toward. The Food and Drug Administration has
recently cleared a number of new products to improve water quality and
time is needed to evaluate their effectiveness. The Association encourages
manufacturers of new products to submit those products to the ADA Seal
of Acceptance program for evaluation.
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Q. Is the water in my dentist’s office safe?
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Q. How soon will dentists have devices meeting this new (200
CFU/mL) goal in their offices?
◦ A. Scientific reports have not linked illness with water passing through
dental waterlines. However, patients should feel free to ask their dentist
about the quality of their dental treatment water or any other aspect of
their practice. To help reduce the number of microorganisms in treatment
water, the Association recommends that dentists follow the infection
control guidelines of the CDC and ADA. This is in addition to other
precautions that your dentist may have in place.
◦ A. The current trend is toward dental units with features to enhance water
quality. The FDA has recently cleared a number of new products to
improve water quality and time is needed to evaluate their effectiveness.
That's why the ADA is continuing its leadership in education and research
in this area. The ADA strongly urges manufacturers to submit their devices
for dental unit waterline use to the ADA Seal of Acceptance Program for
scientific evaluation, which allows dentists to choose products with even
greater confidence.
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Q. Does the ADA oppose government regulations on this issue-even if legislators adopt the ADA's own goal?
◦ A. Yes. The ADA favors a voluntary goal and strongly opposes any effort to
turn a scientific goal into a legal dictate. The dental profession has an
excellent, proactive record on this and other safety issues. In fact, the
dental profession has led the way when it comes to improving water
quality. Because of the ADA statement issued in 1995, the research and
dental industries have responded very positively to this issue. The number
of products (approximately 25) cleared by the FDA for improving water
quality reflects this response.
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Q. What should patients know about waterlines?
◦ A. Patients should always feel free to ask their dentist about water quality
or any other aspect of their practice. Patients also should inform their
dentist of any health problems and medications they might be taking so
the patient and dentist can make the right treatment decisions.
Both dentists and patients should also feel free to visit the ADA
website at www.ada.org for more information.
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CFU = Colony Forming Units of Bacteria
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Federal Water Quality Regulation is 500 CFU/mL
Dentist with City Water Feed - 375,000 CFU/mL
Dentist on CWS bottle - 1,200,00 CFU/mL
Dentist on CWS bottle/w cleaner - <200 CFU/mL
Highest# in a dental waterline - 41,000,00 CFU/mL
Newly mfd. dental unit – 5,000,000 CFU/mL
Toilet water – Anyone want to guess?
Dental unit water line
Tap water line
Very small diameter 1/16”-1/8”
½” diameter
Very slow flow rate drips/sec
5 L/min flowrate (>1000x dental)
Plastic tubing is hydrophobic making
biofilm attachment easy. The tubing
is also a source of carbon for the
bacteria.
Copper as a metal and as a
dissociated ion is
Antimicrobial/Bacteriostatic
Large surface area to volume ratio
Small surface area to volume ratio
Rough interior (extrusion molded)
Smooth interior
Left stagnant for long periods
Fresh every time turned on
Chlorine rapidly dissipates over 24
hours and can even be absorbed by
the tubing.
Chlorinated and replenished with
every use.
Distilled Water
City Water
No Chlorine
Chlorinated
No Minerals
Calcium, Lime, Rust, etc.
$0.50-$1/gal on average
Free out of tap
Must be delivered or made onsite
Dispensed out of tap
Not sterile
Not sterile
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My syringe and/or handpiece leaks water.
I can’t get water out of my handpiece.
The patient says that the water tastes funny.
Why does the city demand I get an RPZ valve?
What are these colored stringy things?
Why is the water foaming?
◦ How many offices represented here have all of their
operatories operating off of a bottle?
◦ Did you know that it costs about $250 per
operatory to convert a city fed unit into one that
operates off of a bottle?
◦ The vast majority of new delivery systems come
equipped with clean water systems because the
cost to not have a clean water bottle is actually
greater for the doctor and the manufacturer.
CWS: The Disinfectant Delivery System
DCI International
8145 Clean Water System
$165.00
◦ Clean water bottles were originally designed for
mission work where water quality was questionable.
They allowed a dental unit to be portable.
◦ Introduction of RPZ valve forced an expensive
choice of city water vs. bottled water systems.
◦ Media & Patient concerns caused a major shift
towards the bottle for its ability to allow the use of
disinfectants.
Series 009 Watts Reduced Pressure
Zone Assemblies prevent the reverse
flow of polluted water from entering
into the potable water supply due to
backsiphonage and or backpressure.
Watts Series 009 is ideal for protection
of health hazard cross-connections or
for containment at the service line
entrance.
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These expensive valves are required to be
installed for any delivery unit not on a
CWS. They are also required by law to be
inspected by a plumber on a regular basis.
Cost estimate > $500 + space
requirements & inspections.
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Limited water volume – You have to change bottles
frequently and filling and changing the bottle takes
time.
Cost and additional handling of distilled water if it is
used.
Disinfection procedures take time and if they are not
done properly, the water will either taste/smell bad
or the unit may be damaged or have a higher
contamination than if it were connected to city water.
Bottles can explode although this problem has been
basically eliminated due to HDPE bottles.
Bottles get over-filled by staff causing water to get
into the air lines of the unit.
Fill the bottle to a point that is
about 1” down from the neck of
the bottle. This amount of air
space will allow for the
displacement that the feed tube
will cause. It will also help
protect the air delivery system
of the clean water unit from
water contamination. If you do
not have a sink that has a long
enough neck on it to fill the
water bottle, the use of a
funnel is recommended.
DCI 8164
2 Liter Bottle $12
Larger capacity for
longer run times
between changes
DCI 8941
Quick Switch Kit $70
Allows a quick change of
the bottle.
◦ And his name is “biofilm”.
◦ Biofilm (a definition): A biofilm is a complex
aggregation of micoorganisms marked by the
excretion of a protective and adhesive matrix. They
are often characterized by surface attachment,
structural heterogeneity, genetic diversity, complex
community interactions, and an extracellular matrix
of polymeric substances.
Biofilm lifecycle
5 stages of biofilm development.
Stage 1, initial attachment
Stage 2, irreversible attachment
Stage 3, maturation I
Stage 4, maturation II
Stage 5, dispersion
Each stage of development in the diagram is paired with a
photomicrograph of a developing Pseudomonas aeruginosa
biofilm. All photomicrographs are shown to same scale.
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Bacteria populations double every 20 minutes
◦ Example:
1 Bacteria
4096 Bacteria
134,217,728 Bacteria
@8 AM
@12 NOON
@5PM
This average assumes the untreated water is left
stagnant at room temperature. Which is exactly what
happens over night, or on weekends in delivery units.
A clean water source that is attached to an infected unit
becomes contaminated within 5 minutes of
introduction to the unit. This contamination peaks at
about 24 hours.
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Some of it comes from the original source water.
Sterile water being the only exception to that rule.
Most of it comes from retraction. This is why some
units have higher contaminations than others. It
depends on who was seen in the chair and how badly
the unit is retracting. Pretty disgusting isn’t it?
Bacteria in Patient #1
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gets delivered to
Healthy Patient #2
Some comes from the air used to pressurize the
water bottles.
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What is it?
◦ Retraction is the action that occurs when a water relay
within the dental unit shuts off and draws water back into
the device.
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Is it bad?
◦ It is bad because if the level of retraction is great enough, it
will draw bodily fluids back past the handpiece that is being
sterilized and into the handpiece hose that is not.
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How do you test for retraction?
◦ We install a small 7” piece of clear tubing on the end of the
handpiece hose. We step on the foot control and then let
up. We measure how far the water gets drawn back.
As the water valve stem
moves to an off position, it
retracts water.
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We install an anti-retraction valve.
◦ It is in-expensive.
◦ It only allows the water to flow in one direction.
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Why does the anti-retraction
valve fail?
◦ As with most leakage problems within a
delivery unit, check valves fail due to
contamination from biofilm.
◦ Once this occurs, the check valve needs to
be replaced.
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We provide a test kit.
You use this test kit to take samples of your
dental unit water in each operatory.
The test kit is mailed into a laboratory.
They test the water and contact you with the
results.
Testing for the problem
ConFirm Monitoring Systems, Inc.
90401 Waterline test kit $95.00
Dental Unit Waterline Testing Service Instructions
1. Place refrigerant pack in the styrofoam lid and place in freezer overnight.
2. Flush waterlines for a minimum of 2 minutes before taking samples.
Sampling should always be conducted just prior to any scheduled waterline maintenance or treatment.
Samples must be shipped on Monday, Tuesday, and Wednesday only. Do not ship samples on any day
preceding a holiday.
3. Collect DUWL samples using sterile collection vials. Fill vials to approximately ¾ full. Do not touch the
outlet of the waterline or the interior of the collection vial. Note: The collection tubes contain a dehydrated
chlorine neutralizer which is visible in the bottom of the vial.
4. Label each DUWL sample. Use a permanent marker or the labels provided. Indicate the sample location and
the type. I.e. Operatory 3, air/water syringe (Op3, a/w).
5. Complete sample submission form and return with samples.
6. Place the frozen refrigerant pack with the water samples in the styrofoam shipper. Place the styrofoam
shipper in mailer box.
7. Complete US Express Mail shipping label and affix to box.
8. US Express Mail can be picked up by your US Post Office mail carrier or delivered to a Post Office. It must
be picked up or delivered the same day the samples are taken, and sent overnight.
9. If you have any questions, please call customer service at 800-819-3336. Results will be faxed or e-mailed
after 7 days of incubation.
Dental Unit Waterline Testing Instructions
We recommend initial testing and subsequent
testing as you see fit. Manufacturer recommends
monthly testing of waterlines to ensure you are
meeting established guidelines.
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There are so many different methods and
chemicals available it is mind boggling.
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Dry flushing
Bleaching (5.25% sodium hypochlorite 1:10 ratio)
Filtration (iodine inline filters, clearline)
Sterilization (UV lights)
Shock treatments (Mint-A-Kleen, Sterilex)
Tablet in bottle treatments (BluTab, ICX)
Sterilizable water delivery tubings
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Use city water in your bottle. (It is free and readily
available. Distilled is better if the office wants to pay for
it. Distilled water is only better if a disinfectant is being
used otherwise it is worse.)
Use the BluTab product in each and every bottle. (The
water does not have to be dumped out and is good for 28
days.)
Shock your waterlines using Mint-A-Kleen - this removes
the biofilm buildup. (I recommend that this be done at
least monthly and whenever the unit will not be used for a
few days.)
Test your waterlines yearly or as frequently as you want to
afford.
Daily Treatment of waterlines
ConFirm Monitoring Systems, Inc.
BT50 750mL BluTab Tablets 50/box
$27.95
BluTab® BT50 Waterline Maintenance Tablets
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BluTab® Waterline Maintenance Tablets are formulated specifically for dental unit
waterlines.
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BluTab® is designed to be continuously present in your waterlines and helps keep
lines clean.
Directions for Use:
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1) Place tablet or tablets (see table below) in empty dental unit water bottle every time
you refill the water. BluTab® is intended for use with potable water (including tap or
distilled).
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2) Fill bottle with desired volume of water and connect to dental unit. Tablet dissolves
in a few minutes.
3) BluTab® may be left in the waterlines overnight and for extended periods of nonuse. BluTab® has been shown to be effective for up to 28 days. Use water solution
until it is expended; or up to 28 days. It is not necessary to purge lines at the end of
each day.
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4) BluTab® is not intended for use as a biofilm removal agent. Before starting a
treatment program with BluTab®, flush lines with an antimicrobial product registered
with the U.S. EPA which is appropriate for use in dental unit water lines. Repeat
flushing protocol every two months. Consult with the manufacturer of your dental
unit or water delivery system to determine the best method to flush your water
system. For a list of recommended products, call 1-800-819-3336.
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Clinical monitoring of water quality can ensure that procedures are performed
correctly. Test water quality monthly to establish effectiveness of your maintenance
program. If water quality results approach or exceed the CDC recommended bacteria
counts, repeat flushing protocol.
BluTab Use Directions
Note: Used daily, per bottle to keep
water clean. Product does not
remove biofilm.
Mint-A-Kleen product
Anodia Systems
2000-500 Box of 10 500mL bottles
$115.00
Mint-A-Kleen® is a light blue, mint flavored solution for use in operative, scaling procedures and cleaning dental
unit’s waterlines.
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Mint-A-Kleen® is bottled in 16 oz. bottles.
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Use Mint-A-Kleen® to cleanse dental unit water lines and dental units heavy-duty water bottle.
Waterline Cleaning Procedure:
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After the last patient leaves;
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Purge waterlines with air.
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Inject Mint-A-Kleen® into all waterlines and allow to remain overnight.
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Next morning purge the waterlines with water for 30 seconds.
Operative/ Hygiene Procedures:
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Solution used in place of water during operative/scaling procedures
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Mint flavoring helps to mask bad tastes and smells.
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Decrease wear on handpiece and burs.
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Less smear layer on tooth’s preparation.
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Increase cutting efficiency with improved cutting on tooth structure.
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Increase patient cooperation.
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Less exposure to aerosols due to the viscosity of Mint-A-Kleen® .
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Lubricates tissue during scaling or operative procedures.
Use with designated pressurized system for high speed handpiece. SAFE: Contains no toxic products, palatable.
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Mint-A-Kleen® is recommended to clean the biofilm when using such systems as
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ultraviolet lights, iodine filters, and filtering systems that treats the water.
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* The pressurized system is activated by the foot control and is for designated handpiece.
Mint-A-Kleen Use Directions
Can be used alone, or as a shock
product when using tabs.
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Timeline
1990 – “CBS 60 minutes/Street Scenes” Florida AIDS Dentist – Bring on handpiece
sterilization.
1993 – CDC recommends that dental waterlines be flushed at the beginning of the clinic day
to reduce the microbial load.
1995 – ADA asks dental manufacturers to provide equipment with the ability to deliver
treatment water with < 200 CFU/mL.
1995 – JADA September Vol. 126 “Contribution of Biofilm Bacteria to the Contamination of
the Dental Unit Water Supply”
1995 – We begin retrofitting units with Clean Water Systems.
1996 – We offer free anti-retraction testing to our clients – The ADA recommends that
handpiece waterlines be checked every six months to ensure they are not retracting saliva.
1996 – A-dec publishes 85-0983-00/12-96 “A-dec’s Detailed Steps to Weekly Waterline
Asepsis” – This guide details the use of 1:10 bleach (5.25% sodium hypochlorite) solution.
1999 – In our newsletter, we introduced Sterilex Ultra-Kleen as a replacement for the 1:10
sodium hypochlorite (bleach) procedure. Ultra-Kleen uses a combination of oxidation,
hydrolysis and solubilization to destroy and break up biofilm. The bleach solution was
eating all of the metal fittings within the units.
1999 – A-dec endorses the use of Ultra-Kleen – “A better alternative (less damaging) to
bleach is the use of commercially available product called Ultra-Kleen.”
1999 – M.R.L.B. International markets their Denta-Pure Iodinated cartridges for use on the
end of the handpiece hose. They stop the retraction problem and bring CFU counts to zero.
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2000 - ABC’s 20/20 February 18th show airs “The Dentist’s Dirty Little Secret” where they tell
the general public that toilet water is several times cleaner than dental delivery system water.
Brought to light the problem of “suck back”
2000 – Massive numbers of dentists sparked by the PR nightmare that 20/20 brought to
light, order clean water systems.
2000 – June R-Tech begins marketing Bio 2000 (Mint-A-Kleen) a chlorhexidine product in
place of Sterilex due to the fact that we had been experiencing problems with crystalline
build up at the points of use from Sterilex use.
2004 – A-dec comes out with ICX tablets that uses three primary active ingredients: sodium
percarbonate, silver nitrate, and cationic surfactants. The tablet eliminates the need to purge
waterlines at night.
2005 – R-Tech offers ConFirm Monitoring Systems, Inc. BluTab product as a less-expensive
alternative to A-dec ICX.
2008 – Present recommendation:
Use a tablet product such as BlueTab or ICX in all of your bottles of water
Use a biofilm shock product such as Mint-A-Kleen or Sterilex once a month or more
frequently if waterline testing shows a higher than normal CFU/mL.
Test your waterlines yearly or as frequently as you want to afford. ConFirm
recommends monthly testing.
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ADA Statement on Dental Unit Waterlines
Adec’s Self-contained Water System Owner’s Guide, Publication No. 85-0675-00
Adec’s Systems Guide, Publication No. 85-0801-00
Anodia Systems product literature
Clearline Microfiltration advertisement
Compendium, Vol. 17, No. 7, July 1996 Starting pg. 691
Confirm Monitoring Systems product literature
DCI International product literature
“Dental Unite Waterlines – Taking the High Road… Now” Dentistry Today August
1997 by Dr. Gary Kono, D.D.S.
“If we had only Known… Reactions to Dental Waterline contamination” Dean Swift
B.Sc. B.Ed. FADM
JADA, Vol. 126, September 1995 starting pg. 1255
JADA, Vol. 128, September 1997 starting pg. 1235
Sterilex product literature
Wikipedia.org/wiki/biofilm
www.bioeng.washington.edu (Dr. James Bryers video speech)