Waterline Treatment

Waterline disinfection helps ensure a safe patient visit

By Laura Thill

It may be rare for dental patients to develop waterborne infections. But, why take a chance? Aside from presenting a health risk for patients, outbreaks of infection linked to the dental waterline can be a liability risk for dental practices.

“Dental unit waterlines must be effectively and efficiently treated to maintain acceptable safe and approved colony-forming-unit (CFU) counts,” says Leann Keefer, RDH, MSM, director, educational and professional relations, Crosstex. “Municipal (source) water delivered to the office meets EPA standards. The perfect storm begins to brew when water is passed through the 6 feet of 2-mm-diameter dental unit waterline tubing. Narrow bore tubing, low flow rates with periods of stagnation, and an ongoing wet environment provide the perfect conditions for bacterial growth.”

For years, both the Centers for Disease Control and Prevention and the American Dental Association have promoted safe dental water standards. “As of 2000 in the United States, per ADA recommendations, dental water should contain no more than 200 colony-forming units per milliliter (CFU/ml),” says Jerod Mendolia, marketing assistant, Sterisil. “More recently, the CDC recommended this water meet EPA standards for drinking water of 500 CFU/ml. Comparatively, the U.S. Army has set its standard at <200 CFU/ml for non-surgical procedures. The European Union and Japan have gone one step further and specified dental unit effluent water be maintained to =100 CFU/ml.”

To help dentists comply with safe water standards, companies like Sterisil and Crosstex continue to take measures to ensure water purity throughout the practice.

The sole focus
At Sterisil, the company’s sole focus is waterline disinfection. “That’s it,” says Mendolia. “Whether an office has 2 ops or 200, we can apply the knowledge gained from almost 20 years of waterline experience to help them meet their compliance goals. We not only develop products, we have created daily protocols and quality assurance programs that are manageable, effective and safe. Our new innovations, like the Sterisil Straw V2, features upgrades that simplify their use and free practitioners from time-intensive maintenance.

“Sterisil products are designed as a complete protocol to ensure the highest level of water purity is met,” he continues. “All Sterisil products come with a shock treatment and are backed by an EPA registration and a quantified claim for disinfection equal to or less than 10 CFU/ml. When it comes to success, we have low expectations – for bacterial content that is. Compliance with the CDC standard of =500 CFU/ml is easily attained when both the shock and maintenance routines are performed properly. The result is customers who are confident in their waterline treatment protocols and know they are providing safe dental water to their patients, staff and environment.”

A solution for any operatory
Dental practices installing a waterline treatment system must choose between an independent bottle-fed configuration and a municipal direct-feed configuration, Mendolia explains. There are pros and cons to both options, he adds. “An independent bottle-fed configuration offers the maximum control over what goes into the waterline,” he says. “In municipalities where there may be more than one municipal source, water quality can vary throughout the year. An isolated bottle reservoir using distilled water maintains consistent water quality despite changes in the municipal supply. Since OSAP recommends using a shock and daily maintenance component for complete waterline disinfection, independent bottles provide easy access to perform both, compared with other configurations.

“A bottle-fed configuration using distilled water in conjunction with a Sterisil Straw offers maximum reliability with respect to water quality over the lifespan of the product, since the content of the water remains at a constant,” he says. “The downside of bottle-fed configurations is the level of daily involvement required from the staff to refill bottles when they run empty. If staff efficiency is the goal, they should look into a Sterisil System G4 configured for direct feed.

“Municipal direct-feed configurations, on the other hand, excel at reducing daily staff involvement,” Mendolia continues. “However, the variable quality of the public water supply will play a factor in the lifespan of the waterline product. Calcium buildup in handpieces and waterlines are common and can be costly to repair. With the Sterisil System G4, water quality is improved before it ever reaches a handpiece. Continuous monitoring via onboard sensors trigger an alarm when water quality degrades above a certain threshold, at which point staff would only need to perform a quick cartridge replacement and continue using as normal.”

Using distilled water in a bottle reservoir is the best solution for dental waterlines and chairs, and ultimately leads to the best disinfection results, Mendolia points out. That said, “Sterisil recognizes this isn’t always feasible, which is why we have a full line of products to meet any office configuration,” he adds. The company also offers a line of accessories, including silver impregnated Biofree bottles. “Going one step further, periodic bacteria testing performed by a third-party lab specializing in dental waterlines can provide an accurate assessment of water purity,” he says. “Water testing is affordable and offers dentists assurance the protocols they have in place are effective. If an office fails a water test, Sterisil customer service will do an in-depth investigation into their protocols and configuration, and recommend a plan of action.”

Easier and more cost effective
Best practices are changing all the time, notes Mendolia. As recently as December of 2016, the EPA issued a final ruling, which established best management practices for amalgam separators and dental effluent water.

“The science behind biofilm growth shows us the dental waterline is an ideal breeding ground for pathogens,” he says. “According to the ADA, waterlines left untreated can easily exceed the drinking water standard of =500 CFU/ml. With the development of ion exchange delivery systems employed by Sterisil products, waterline treatment is easier and more cost effective than ever.” Some dentists may regard waterline maintenance as an unnecessary cost. But, “most skeptics, when presented with the evidence, will weigh the cost of treatment against the cost of a potential outbreak and come to the logical conclusion to treat their water.”

Education and sound solutions
Solid science compliance is key to successful dental unit waterline treatment protocols, according to Leann Keefer, RDH, MSM, director, education and professional relations, Crosstex. “As a leader in infection prevention and control, Crosstex is committed to scientifically based programming to address best practices of infection prevention to provide a safe dental visit for the patient, clinician and the practice,” she says. Indeed, the company is big believer in providing its dental customers with strong educational programs and sound solutions to help them protect their patients and staff.

“Crosstex products, such as DentaPure® Cartridges and Liquid Ultra™ Solution, help ensure compliance with EPA standards for potable water,” says Keefer. DentaPure cartridges are EPA registered to provide water =200 CFU/mL, she points out. In fact, “the DentaPure cartridge uses the same technology developed for NASA to ensure that water consumed in space is safe from harmful levels of bacteria.” Similarly, when used as directed, Liquid Ultra is EPA registered to provide water =500 CFU/mL and is the only EPA approved in-line product that kills biofilm, she notes.

By providing educational resources to clinicians and distributor field sales reps and service technicians, and by arming sales reps with patient resources to share with customers, “Crosstex has created educational touchpoints in every arena of safe dental unit waterlines,” says Keefer. “Crosstex is an AGD PACE-approved provider with CEU programs at national meetings and on-site practice-based learning events, and through VIVA Learning for live and on-demand webinars. Our Client Care team and educational toll-free STERILE Helpline (1-8558-STERILE) are ready to address both clinical and regulatory questions.”

Easy maintenance
Dentists appreciate the value of infection control protocols, including waterline treatment. But, some may express concerns about managing the compliance process and maintaining records. Once installed, however, the DentaPure cartridge requires no monitoring or shocking for 365 days, or 240L of water usage if records are maintained, notes Keefer. “If an office is concerned about monitoring CFU counts, we recommend independent testing by an outside laboratory,” she says. “For offices that are concerned that the iodine level stays within the range provided in the DentaPure cartridge IFU, Crosstex offers iodine test strips.” Testing frequency – both for CFU counts and iodine levels – varies by practice, she adds.

As with any product, dental practices should follow manufacturer recommendations. Crosstex offers the following best practices:

  • Flushing for 20 – 30 seconds between patients.
  • Sterilizing all handpieces after each use.
  • Emptying independent water bottles nightly and setting them upside down to dry to avoid biofilm growth from untreated water remaining in the bottle.
  • Wiping down the outside of the cartridge with a clean paper towel before replacing the bottle.
  • Filling bottles with fresh water (tap or distilled) each morning before each use.

Minimizing your risk
Some dentists may not realize that improperly or poorly treated waterlines can place their patients and staff at risk for infection, as well as create a liability risk for their practice. Others may believe they are taking sufficient steps to reduce the risk, when, in fact, they are not. Indeed, using distilled water, cleaning bottles daily and refilling them with fresh water, and installing filters are not enough, according to experts. And, while waterline cleaner tablets provide a good start, total compliance is required each time the water bottle is filled, and the practice often doesn’t follow up to ensure tablet protocols are followed consistently.

Using products like the DentaPure cartridge reduces the amount of time the staff may need to dedicate to dental unit waterline treatment,” says Keefer. “Once installed, there are no monitoring or shocking protocols required. There is no need for daily tablets or routine shocking. And, one cartridge installation equals 365 days (or 240L of water if usage records are kept) of safe, compliant dental unit water.”

Editor’s note: All DentaPure claims are based on use with potable water.

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