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Preventing biofilm in Dental Unit Waterlines (DUWL)

by Patti DiGangi, RDH, BS

The waterlines of a dental unit promote bacterial growth and the development of biofilms due to the dark, long narrow tubing, slow flow rates and periods of stagnation. According to OSAP (Organization for Safety, Asepsis and Prevention), waterline contamination consist of slime-producing bacteria, fungi and protozoans.¹ The microorganisms will begin to adhere to the walls of the tubing. As they grow, they develop a protective polysaccharide layer, which allows for the collection of even more microorganisms. Over time, they eventually break free and these heterotrophic microorganisms become planktonic-free floating microorganisms. They can find their way to areas of the tubing to grow another biofilm colony or into a patient's mouth where they can potentially cause harm. 

Monarch Lines Cleaner is a fast and effective way to shock and maintain waterlines in one single product. It gently removes biofilm from DUWL containing odor-causing bacteria in a non-corrosive solution. After the initial shock treatment, the lines only need to be treated once a week. Each treatment requires 2 oz. of solution, which is poured directly into the water bottle undiluted. 

Not all DUWL cleaners are treated equal. Monarch Lines Cleaner also meets the ADA and EPA guidelines. The product was tested in the Dental Advisor labs over a 3-month period. Bacterial concentrations met or were below 500 Colony Forming Units (CFU) per ml as recommended by the EPA. This level was observed just after a few days of treating the lines. The EPA established The Safe Drinking Water Act (SDWA). It is a federal law that protects public drinking water supplies. Under the SDWA, the acceptable CFU count is 500 CFU or less per milliliter of water.

When it comes to keep ourselves, patients, and communities safe, cleaning DUWL should be a part of our infection control checklist and maintenance daily. Implementing the Monarch Lines Cleaner is a safe and cost-effective way to reduce biofilm contamination. Now, more than ever, our patients are aware of the importance of infection control. The Monarch line provides clinicians with the confidence of biofilm elimination our patient's deserve.

 

Contact your local Air Techniques Territory Manager for additional upgrades available. 

Or Contact Air Techniques directly:

Phone: 516-433-7676

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Importance of Routine Steps Performed Consistently Saves Lives

The World Health Organization (WHO) declares the coronavirus outbreak a pandemic screams the headlines. Covid-19 puts into sharp focus the importance of standard precautions and infection prevention. With fear running rampant, as dental professionals, we can know that our standard precautions training and education will keep us as safe as possible.if we follow them consistently.

 

The Organization for Safety, Asepsis and Prevention (OSAP) talks about creating a Culture of Safety. It involves a commitment to the safety of patients and personnel by everyone in the organization (office/institution), including management. OSAP's Summary of Infection Prevention Practices in Dental Settings Basic Expectations for Safe Care is a concise document that outlines the steps that must be taken by all practice personnel when turning over a room between patients. This includes dental unit water lines and vacuum systems.

 

The mode of transmission of the Covid-19 virus is still not completely clear. Water quality safety has never been more important. The narrow gauge of dental unit waterline makes them a breeding ground for biofilm growth and the potential spread of infection. Bacteria and other microorganisms form a biofilm, which adheres to the inside of the tubing that supplies water to the dental instruments. As water moves through the tubing, or waterline, microorganisms slough off into the water, thus contaminating it. Spraying water can spread viruses and infections.

 

The guidelines calls for flushing dental water lines for a minimum of 20 to 30 seconds after each patient, from any device connected to the dental water system that enters the patient's mouth (for example, handpieces, ultrasonic scalers, and air/water syringes) as well as at the beginning and end of the patient day. This step is often skipped in a desire to stay on schedule. 

 

The same is true for our evacuation system. Suction lines should be cleaned every day with an evacuation system cleaner to remove blood and debris, and a disinfectant that is compatible with the evacuation system should be run through the tubing. Monarch CleanStream has a unique formulation designed for daily cleaning. It penetrates and helps remove line buildup while maintaining vacuum performance and suction.

 

These essential steps from OSAP could save a life, maybe even yours.

Infection Control Isn't Only About You;
It's About the Patients 

by Michelle Strange, MSDH, RDH

In any profession, it is not unusual to hear things like "I have done this for 17 years, and I haven't had any problems. Why change now?" While relatable, it's not a good mindset to have in the dental profession. Dentistry is always evolving, which means that we must also if we wish to offer patients the best care possible. 

In dentistry, infection control practices are not about us, but about the people who enter our facilities and sit in our chairs. Patient health must be the utmost concern, as it only takes one person catching an infection to put our practices and licenses at risk, nevermind the person's suffering because of our mistake. 

The biggest dangers come from healthcare-associated infection, medication errors, and unsafe surgery. As documented in many studies, numerous infectious outbreaks are due to a lack of compliance with established guidelines for disinfection and sterilization. When incidents happen, patients can be affected by minor to life-threatening ways ranging from temporary to permanent injuries or even death. Patients often advocate for themselves, but at the end of the day, it's still on us, the healthcare professionals to properly care for our patients. 

To improve the system and help prevent dental-related infections you can:12 

1. Develop relationships with your patients and embrace the importance of human connection. 
2. Avoid blaming when mistakes occur. Instead, question why the error happened and aim never to let it happen again.
3. Remember that Infection control isn't about you or what you want to do. Do for your patients what you would want them to do for you if the roles were reversed.

Employ these strategies to improve the quality of your service and infection control to keep you, your practice, and your patients safer. 

 

 

1 "World Health Organization: Patient Safety" http://go.airtechniques.com/e/392012/curriculum-course1-handout-pdf/r9qpgx/1011632649?h=E7pB2Z61WRsxj4jdDAKkJI9r9JIZOn5IKxQx6GIRZrE. Accessed 5 Mar. 2020.

2 "Disinfection and Sterilization" http://go.airtechniques.com/e/392012/2020-05-14/r9qpgz/1011632649?h=E7pB2Z61WRsxj4jdDAKkJI9r9JIZOn5IKxQx6GIRZrE. Accessed 5 Mar. 2020.

 

From all of us at Air Techniques...

We hope you had a great year!

Reading Disinfection Labels is Very Important
by Michelle Strange, MSDH, RDH

Reading could be one of the most valuable skills that we develop in school. Yet, the older we get, the easier it becomes to "forget to read " because we figure that we already know everything there is to know. However, that couldn't be farther from the truth. In dentistry and infection control, it is imperative to read the labels. Not all disinfectant products are the same, and if not used correctly, the products can become useless. The only way to know how to use a product properly is to read the labels and instructions. 

 

In dentistry, there are different levels of cleaning, disinfection, and sterilization required. Cleaning is a first step, followed by disinfection. Many people might think these terms are synonymous, or that the products for each process are interchangeable, but they aren't. Some products only require 1-step, but you have to confirm by reading the instructions. 

 

Failure to use these different products properly can create extra costs and safety hazards.1,2 According to the CDC, dental offices should only use disinfectant wipes that are approved for use in healthcare settings and follow the manufacturer recommendations. Even then, some products require multiple steps, and it's crucial to follow the label to know how much is needed or if it needs dilution, how long it must make contact with the surface, how to use it safely, and also how to dispose of the cleaning products. 

 

Reading a label only takes a few extra moments, but not reading it can cause a whole host of long-term problems for both your practice and your patients. So, the choice is clear: make sure you read and follow all instructions to make sure that you are doing your part to prevent infection and provide a safer, cleaner dental environment for everyone.

 

1 "Disinfection and Sterilization in Dentistry". http://go.airtechniques.com/e/392012/disinfectionsterilization-/r5yh12/983119197?h=vAzKGUy0wcXF-PmWzkOqQzDHP0GNG7T3A9V33WfonFU. Accessed 5 Mar 2020.
2 "FAQ-  Disinfection" 2018. http://go.airtechniques.com/e/392012/chterms-22instructionsanduse22/r5yh14/983119197?h=vAzKGUy0wcXF-PmWzkOqQzDHP0GNG7T3A9V33WfonFU. Accessed 5 Mar. 2020.

Why Proper Amalgam Disposal
is Essential

The environment is a topic at the forefront, thanks to the upcoming US Presidential Elections and the recent global phenomenon of Greta Thunberg. No matter what your stance is on global warming and the world's carbon footprint, you are impacted by new regulations and rulings that affect the way you dispose and handle the waste. 

According to the EPA, there are approximately 5.1 tons of mercury and 5.3 tons of other metals being discharged by dentists yearly to POTWs¹. Would it surprise you to know that most of this mercury is subsequently released into the environment? Dental offices are the single largest source of mercury at sewage treatment plants².  

What happens to the amalgam waste that becomes part of the POTW's sewage sludge? It's disposed of in one of three ways²:

• In landfills.  If the amalgam waste is sent to a landfill, the mercury may be released into the groundwater or air.

• Through incineration.  If the mercury is incinerated, mercury may be emitted to the air from the incinerator stacks.

• By applying the sludge to agricultural land as fertilizer. If mercury-contaminated sludge is used as an agricultural fertilizer, some of the mercury used as fertilizer may also evaporate into the atmosphere.

     
 After knowing these facts, the recent final ruling on amalgam separators by the EPA may make more sense to you. The compliance date for existing dental practices and businesses is July 14, 2020. It is estimated by the EPA that approximately 103,000 USA dental offices use or remove amalgam¹.  

Amalgam is considered safe for its treatment purposes by the ADA and the EPA. It's been used in dentistry for more than 150 years, and gold is the only material that has been used longer for dental purposes.

 How will the use of an Amalgam Separator benefit the environment? The key is keeping as much amalgam and waste out of the POTW's sewage sludge as possible. Amalgam Separators offer an efficient way to separate and collect dental amalgam, mercury, teeth fragments, and other dental waste. Designed to capture amalgam particles from dental office wastewater through sedimentation, filtration, centrifugation, or a combination of these mechanisms.³ 

What are the facts you need to identify when choosing an Amalgam Separator to meet compliance? First, know the requirements that the system needs to meet set in the EPA ruling.
⁴Chart

• Ensure the removal of dental amalgam solids from all amalgam process wastewater via amalgam separator(s) or equivalent device(s) that achieve at least a 95% removal efficiency and meet EPA standards set by the final  rule ? 441.40.

• Implementation of two best management practices. See ? 441.30(b) for an existing source and ? 441.40 for a new source.

• Comply with reporting requirements. See ? 441.50(a).

• Maintain and make available for individual inspection records documenting compliance. See ? 441.50(b)
   

When choosing an Amalgam Separator for your practice, do your research online, speak with your colleagues, and your trusted dealer rep. Become familiar with your state or local requirements as those might be sterner than those in the rule. Learn about installation requirements set by your municipality. Lastly, be ready to commit to a recycling program. The collection containers must be recycled appropriately to comply. Many manufacturers, including Air Techniques, offer a recycling program. This is often part of the collection container purchase, resulting in a seamless process for dental facilities.     

 

 Sources:

1.     http://go.airtechniques.com/e/392012/eg-dental-effluent-guidelines/qy3pjc/936295936?h=Cn_20GGUfMPgocM03gXCh-aD_2pBN9C3IBR4vSo_A_0   
2.     http://go.airtechniques.com/e/392012/mercury-mercury-dental-amalgam/qy3pjf/936295936?h=Cn_20GGUfMPgocM03gXCh-aD_2pBN9C3IBR4vSo_A_0     
3.     Chou HN, Anglen J. An evaluation of amalgam separators. J Am Dent Assoc 2012;143(8):920-21.
4.     http://go.airtechniques.com/e/392012/requent-questions-nov-2017-pdf/qy3pjh/936295936?h=Cn_20GGUfMPgocM03gXCh-aD_2pBN9C3IBR4vSo_A_0  

High-Volume Evacuation Versus Saliva Ejectors

by  Michelle Strange, MSDH, RDH

Different dental procedures require varying tools just as a contractor would not hammer a screw when building a home-it might do a similar job, but it is nowhere as effective. The same applies to the comparison between high-volume evacuators (HVE) and saliva ejectors. Saliva ejectors tend to be used during routine and straightforward procedures where fluid needs to be removed from the patient's mouth, whereas HVEs are necessary during more extensive dental work because of their ability to quickly remove build-up of liquids and larger solids that the saliva ejector can't evacuate. With the added benefit that HVEs can also reduce aerosol production by 90-98%. Understanding the appropriate and proper use of both tools is vital.

 

Flow Rate and Suction Volume 

Performing dental procedures can be challenging if a practice's vacuum system/HVE is inadequate. Without a proper vacuum system, dental professionals could be making efforts to prevent aerosol contamination, without correctly judging the airflow level that produces adequate suction for clinical purposes. Many dental team members have walked into the office, flipped the switch on to the vacuum, compressor, and water without thinking about the system being fully capable. Most practices however do not have the ability to monitor or check air flow from the HVEs. This requires specific instruments which are only recently available through some manufacturers (such as Air Techniques). So, most practices would not be able to check this themselves or even through their dealers unless they had an AT Sales Rep or Technician do a special on-site visit. This has become even more important during the current pandemic. There is more to understand regarding the use of this great engineering control that is meant to reduce the risk of spreading aerosols including the required minimum airflow levels for producing adequate suction.

 

HVEs and Saliva ejectors perform two different functions

Saliva Ejectors are for removing saliva and pooling water during patient care, HVE's are meant for specific uses during a procedure like crown preparation, extractions, and to help reduce the spatter and spray during dental hygiene procedures.
Although saliva ejectors are useful during routine dental procedures, they do not have the power needed to limit the spread of aerosols. After all, aerosols can remain in the air and travel throughout the dental practice, posing a risk to all staff, even after the infected patient has left the building. The use of a high-volume evacuator dramatically reduces the risk of these aerosols escaping from the patient's mouth. Keep in mind this requires the dentist or hygienist to use their free hand always with the HVE, or it requires a second assistant to hold a free HVE specifically for this purpose.

 

HVE Tips without High-Performance Vacuum Systems 

Yes, we will need a saliva ejector to help the pooling of fluid in the patient's mouth, but an HVE will be what is needed for most of our procedures in dentistry.  We create spatter, spray, and aerosols for most of what we do so becoming accustomed to using our HVE is incredibly important. However, we have to think past the HVE tip and consider the vacuum system that is really the workhorse in this situation.

 

To help eliminate infectious aerosols spreading throughout dental offices, the Mojave Dry Vacuum can "provide the highest operational performance" required. The higher-flow vacuum is consistent and provides an exceptional level of suction without the noise levels of older models. It can adjust speed to accommodate the number of users online without the performance suffering.

 

The system will always provide the right speed, suction, and flow to ensure a safe and reliable dental procedure for both the patient and the staff. With low maintenance and offering 85% energy savings compared to other systems, the Mojave can save dentists money.

 

HVE's are amazing engineering controls and should be the choice for aerosol reduction during dental procedures.  We just have to remember they only work when we use them and only as good as the vacuum system to support their performance.

 

Keeping oil out of your patients mouths

and restorations

Your practice is depended on a reliable supply of Dental Compressed Air. A good working definition of Dental Compressed Air is "Dental quality compressed air completely free of oil, ultra-dry and contains as few microbes as feasible." 

 

Air is not just air. Quality air is combined with freed contaminants such as industrial exhausts, particles of soot from vehicle exhaust systems, and microorganisms that can cause disease. Natural and human-made risks are invisible and lurk in the air around us. We are hardly aware of just how many ways compressed air plays a vital role in dentistry. It drives a complete series of appliances and components - from the turbine in the handpiece to pressure-molding devices to actuating precision cutters in the laboratory. Dental air is also used for cleaning dental models and for drying directly inside the mouths of patients.

 

 

So how does oil affect air quality?

 

Oil in the compressed air stream is a contaminant. Even with filtering systems, it is impossible to remove all oil from the air stream of an oil-lubricated compressor. Bacteria laden air flows into the patient''s mouth and subsequently throughout the operatory environment. Oil aerosol acts much like bad cholesterol in the body; components will become clogged or damaged. This oil vapor can negatively impact health, dental instruments, and restorations. The oil-free air compressor eliminates all of these problems. Recognizing the significant advantages inherent in oil-free compressor design, Air Techniques voluntarily discontinued its oil-lubricated compressor line some years ago.

 

Why is oil-free air healthier and necessary for Dentistry?

The combination of warm air, humidity, and oil in the closed environment of the compressor storage tank creates an ideal growing medium for microorganisms. This unhealthy air flows through the piping, dental unit airlines, and handpieces into the patient''s mouth and subsequently throughout the operatory environment. The oil will also compromise the bond strength of restorations.

 

AirStar is specially designed for dentistry and produces clean, ultra-dry, oil-free dental compressed air 100% of the time. The problems of moisture, oil, and microbes are purposefully engineered out. No oil whatsoever is used. Further, the exclusive patented Humidistat continually monitors the moisture content of the air stream and automatically initiates a regeneration cycle should extra moisture removal from the air ever be required.

Oil-free engineering and stringent moisture control ensure that every AirStar storage tank remains dry and not conducive to microbial growth. Every AirStar storage tank is SME certified, your assurance of safety, and code compliance.

 

Is COVID-19 Potentially Hiding in Your Waterlines Going to Make Your Patients Sick 
by Patti DiGangi

In the time of the COVID-19 crisis, our patients will need even more assurance when they come back to see us that everything is safe. Though they may not realize the risk contaminated waterlines can create, we know and it is our duty to keep them safe. When we are protecting our patients, we are protecting ourselves and our businesses.

Is COVID-19 Growing in the Lines?

Dental unit waterlines (DUWLs) are used daily in dental practices. The importance of proper infection control to maintain the safety of both patients and healthcare professionals is apparent because DUWLs is a breeding ground for infection-causing biofilm.

The microorganisms that colonize in DUWLs can include bacteria, fungi, and protozoans, including Legionella, Pseudomonas aeruginosa, Candida albicans, and nontuberculous mycobacteria (NTM), and can increase in number to cause illness and infection. We must assume they contain COVID-19.

The CDC and the EPA regulatory standards call for < 500 CFU/ml of heterotrophic bacteria in DUWL. Heterotrophs are a group of microorganisms like yeast, molds & bacteria that use organic carbon as food as opposed to autotrophs like algae that use sunlight and are found in every type of water. Research shows microbial counts can reach 400,000 CFU/ml within 5 days after the installation of a new DUWL. That is 400x the recommended level. We know that COVID-19 grows quickly and is readily spread.

Keeping Lines Safe

Although flushing DUWLs was once recognized as an efficient way to control the microbial presence and decrease the planktonic bacteria in water, there are other strategies to control the presence of biofilm. Inside the tubing, water flows in a laminar fashion, meaning in parallel layers with no disruption in those layers. As a result, biofilm adheres to the sides of the narrow dental water line tubing and remains relatively stagnant, allowing continued growth. Biofilm can multiply rapidly and grow in an established, well-protected shell without treatment, so healthcare professionals must use effective methods to maintain water lines for the safety of themselves and their patients.

The product you choose must be an effective biofilm disruptor with rapid kill times. At the same time, it needs to be gentle on equipment and have no effect on restorative materials. Time is money so it needs to be time-efficient as well as sustainable with no harsh chemicals or leave a residue.

This means we must be picky when selecting products. For example, Monarch Lines Cleaner is a powerful formula that helps attack accumulated deposits in tubing lines without the use of harsh or aggressive chemicals.

Protecting Our Patients and Protecting Ourselves

Not only will patients have concerns coming back into the office; so will healthcare providers. With the COVID-19 Crisis, we have seen the importance of personal protective equipment (PPE). Every professional will be taking infection protection seriously more so in the future. We must take care of ourselves in order to take care of others.

Though waterlines may not have been subject to discussion with patients in the past, it can and should be. You can assure your patients you are doing everything possible to keep them safe.

When We Get too Comfortable and Lack Accountability, Patient Safety is Affected 

by Michelle Strange, MSDH, RDH

After working in one place for a long time, there is a human tendency to become somewhat complacent and move into an almost automated working process. However, as relaxing as this comfort is, it can cause problems because it means that you develop a particular set of responses that prevent you from being the most productive worker. Comfortable workers tend to be perceived as lazy, lack enthusiasm/passion, and settle for the bare minimum instead of going above and beyond. In the field of dentistry, this comfort can result in putting your patients' well-being in danger.

 

One reason that people tend to become too comfortable in their working lives is because of a lack of accountability. Without accountability, unproductive behaviors are formed and can result in an environment where mistakes are the accepted norm rather than the exception.

 

In dental offices, professional mistakes often revolve around patient safety and can be something like forgetting to sterilize certain pieces of equipment. Errors like this can cause delays that upset patient satisfaction, but more seriously, they can be an indicator of lax safety rules. Many dental infection control safety guides have comprehensive directions to ensure as much as possible a reduction in healthcare-associated infections. If dental professionals lack accountability, it is all too easy for these tasks to get overlooked or done with complacency that fails to protect patients.

 

So, what can we do? Every dental practice needs to instill a sense of responsibility in their teams. The best way to increase accountability is to follow purposeful hiring practices, provide employees with clear deadlines, open clear lines of communication, have regular evaluations, and work tirelessly to have definitive expectations with clearly defined results. Accountability is the best way to build a high functioning team and limit the effects of accepted mediocrity because our patients deserve more than "just ok" when it comes to their care.

 

1 "4 Signs You're Too Comfortable in Your Job". http://go.airtechniques.com/e/392012/re-too-comfortable-in-your-job/r82xtz/997071117?h=hgqVDNPPBjWv-VGUApYbWLgyJU3D2_wqE_4pFlmZBTE. Accessed 5 Mar. 2020.

2 "Accountability for your actions: Building a dental team culture that matures from its mistakes". 1 May 2017. http://go.airtechniques.com/e/392012/that-matures-from-its-mistakes/r82xv2/997071117?h=hgqVDNPPBjWv-VGUApYbWLgyJU3D2_wqE_4pFlmZBTE. Accessed 5 Mar. 2020.

 3 "Environmental Infection Prevention: Guidance for Continuously Maintaining a Safe Patient Care and Survey-Ready Environment" http://go.airtechniques.com/e/392012/nfectionprevention-2800229-pdf/r82xv4/997071117?h=hgqVDNPPBjWv-VGUApYbWLgyJU3D2_wqE_4pFlmZBTE. Accessed 5 Mar. 2020.

4 "3 Ways to Hold Your Dental Team Accountable". 21 Feb. 2019. http://go.airtechniques.com/e/392012/d-your-dental-team-accountable/r82xv6/997071117?h=hgqVDNPPBjWv-VGUApYbWLgyJU3D2_wqE_4pFlmZBTE. Accessed 5 Mar. 2020.