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By Leann Keefer, RDH, MSM General Manager and Director of Education, Crosstex International n Best practices of infection preven- tion and control provide safety in the clinical environment and treatment protocols for patients and dental pro- fessionals. Exposure to poor water quality can pose a health risk for people and conflicts with universally accepted infection prevention pro- tocols. Noted most recently, in 2011, was the fatal case of an 82-year-old other- wise healthy woman who developed Legionnaire’s disease after a dental visit1 . The goal of effective dental water- linetreatmentistoreducethenumber of microorganisms present in the water, thereby helping to break the chain of infection. Dental unit waterline contami- nation was first reported in 19632 . Researchhasshownmicrobialcounts can reach <200,000 CFU/mL within five days after installation of new dental unit waterlines3 , and contami- nation levels of up to 1 million CFU/ mL of dental unit water have been documented4,5 . In 1995, the American Dental Association issued a state- ment encouraging improvement in the design of dental equipment to offer delivery on the outgoing water quality levels used in non-surgical dental treatment of 200 CFU/mL or fewer6 . Based on standards for potable drinking water by the Environmen- tal Protection Agency, the American Public Health Association and the American Water Works Association, the Centers for Disease Control and Prevention guidelines (2003) state the number of bacteria in water used as a coolant/irrigant for nonsurgical dentalproceduresshouldbelessthan 500 CFU/mL7 . The following options are avail- able to address the biofilm with its resident microorganisms and opti- mize dental unit water quality: • Self-contained water systems • Point-of-use filters • Chemical treatment protocols • Municipal water treatment sys- tems • Slow-release cartridge devices Point-of-use filters placed at the end of each waterline often have pores too large to effectively trap bacteria, as well as slowing the flow of water in the tubing, which con- tributes to biofilm growth, and they provide additional surface area for microbial growth. There is also an ongoing expense of filter replacement every seven to 10 days. Chemical agents available com- mercially are designed to inactivate and remove biofilms or deter attach- ment of biofilm in new or cleaned systems. Daily compliance with tab- lets, along with monthly shocking and quarterly monitoring, are key to these technique-sensitive protocols. Of concern, residue from undissolved tablets is a potential source of costly repairs to handpieces. One innovative waterline disinfec- tion cartridge system, available for municipal or bottled water, offers a continual slow release of iodinated resin. As water flows through the cartridge, it pulls elemental iodine from the resin into the water stream. From there, the iodine interacts with any bacteria in the water, killing it on contact. The cartridge is effective for one- year after being installed, making compliance effortless. This simple system is FDA- and EPA-cleared to provide water under 200 CFU/mL with absolutely no testing require- ment. With no protein attached to the iodine, it poses no risk for aller- gies, and any “unused” iodine evapo- rates into the air. Unlike hazardous heavy metal-based cartridges, the used iodine cartridge can be simply disposed of into the trash. Effective dental unit waterline maintenance is a key component of aninfectioncontrolprogram.Criteria for choosing a dental unit waterline treatment system include ability to control microorganisms and biofilm at required standards; reasonable product and labor costs; safety to equipmentandtheenvironment;and, ultimately, compliance. CDC recommendations • Flush lines at the start of the day and between patients for 20 to 30 seconds. • Establish a protocol to achieve and maintain water lines with less than 500 CFU/mL. • Strictly follow manufacturer’s instructions and protocol for main- taining water quality. • Monitor water quality based on manufacturer instructions. ADA on dental unit waterlines (2004) •Employcommercialdevicestomeet water quality standards of less than 200 CFU/mL. • Monitor biological water quality. • Dental unit water systems must be maintained to deliver water of an optimal microbiologic quality. • Adopt the use of commercial devices to achieve the safe water quality standard of < 200 CFU/mL. • Use EPA-registered and FDA- cleared dental waterline treatment product or device according to manu- facturer’s directions. •Strictadherencetowaterquality protocols. References 1. Ricci ML, Fontana S, Pinci F, et al. Pneumonia associated with a den- tal unit waterline. Lancet 2012;379 (9816):684. April 2012 2. Blake GC. The incidence and con- trol of bacterial infection of dental units and ultrasonic scalers. Br Med J. 1963; 115: 413-416. 3. Barbeau J, Tanguay R, Faucher E, et al. Multiparametric analysis of waterline contamination in den- tal units. Appl Environ Microbiol 1996; 62: 3954–3959. 4. Mayo JA, Oertling KM, Andrieu SC. Bacterial biofilm: a source of contamination in dental air-water syringes. Clin Prev Dent 1990; 12:13–20. 5. Santiago JI. Microbial contamina- tionofdentalunitwaterlines:short and long term effects of flushing. Gen Dent 1994;42:528–535. 6. American Dental Association statement on dental unit water- lines. Adopted by the ADA Board of Trustees, December 13, 1995, and the ADA Council on Scientific Affairs, September 28, 1995. 7. Centers for Disease Control and Prevention. (2003). Guidelines for Infection Control in Dental Health- CareSettings. Retrieved www.cdc. gov/mmwr/PDF/rr/rr5217.pdf. exhibitors10 ADA 2015 — November 6, 2015 Pure and simple: Dental unit waterline compliance Here at the ADA To learn more about DentaPure, which can help with all your waterline needs, stopbythebooth,No.3231,intheTech Expo Arena. 5 Poor water quality can pose a health risk to patients. (Photos/Provided by Crosstex International) 5 The DentaPure can help your waterlines meet CDC and ADA recommendations.