Investigation of the bacterial load and antibiotic susceptibility of dental units

Effective disinfecting of negative pressure pipelines of DCUs reduces the risk of cross infection in dental care

Objectives

Microbial contamination of various accessory parts of the dental chair units (DCUs) is an essential source of cross infection, while the accessories of the crucial suction function are usually overlooked. In this study, we aim to find an effective disinfectant and a cost-effective method to remove bacterioplankton and bacterial biofilm deposited in the negative pressure suction pipelines to control cross infection during dental treatment.

Methods

Double-chain quaternary ammonium salt disinfectant (Orotol Plus®), 3% hydrogen peroxide solution plus multi-enzyme cleaning agent and chlorine disinfectant are used to clean and disinfect the negative pressure pipelines of DCUs. Microbiological examinations, air condition detection, corrosion tests and gene sequencing are performed.

Results

Little bacteria grow in the pipelines disinfected with double-chain quaternary ammonium salt disinfectants, destruction of biofilms in these pipelines appears, and multi-resistant bacteria cannot be detected. Minimal damage to metal sheets and fittings is caused by double-chain quaternary ammonium salt disinfectants.

Conclusion

Double-chain quaternary ammonium salt disinfectant has excellent bactericidal ability and anti-biofilm effect, and it is less corrosive to the fittings of the pipelines. Thus, the double-chain quaternary ammonium salt disinfectant is a potential novel disinfectant for negative pressure suction pipelines of DCUs to control cross infection during dental treatment.

Clinical significance

It is essential to add all these data to our dental practice to control cross infection with a broader landscape.

Bacterial biofilm prevalence in dental unit waterlines: a systematic review and meta-analysis

BACKGROUNDS

Numerous studies have shown that dental unit water lines (DUWLs) are often contaminated by a wide range of micro-organisms (bacteria, fungi, protozoa) and various prevalence have been reported for it in previous studies. Therefore, this review study aims to describe the prevalence of bacterial biofilm contamination of DUWLs.

METHODS

This is a systematic review and meta-analysis in which the related keywords in different international databases, including Medline (via PubMed) and Scopus were searched. The retrieved studies were screened and the required data were extracted from the included studies. Three standard methods including American Dental Association (ADA), The Center for Disease Control and Prevention (CDC) and contaminated > 100 CFU/ml(C-100) standards were used to assess the bacterial biofilm contamination of DUWLs. All studies that calculated the prevalence of bacterial biofilm contamination of DUWLs, and English full-text studies were included in the meta-analysis. Studies that did not have relevant data or used unusual laboratory methods were excluded. Methodological risk of bias was assessed by a related checklist and finally, the data were pooled by fixed or random-effect models.

RESULTS

Seven hundred and thirty-six studies were identified and screened and 26 related studies were included in the meta-analysis. The oldest included study was published in 1976 and the most recent study was published in 2020. According to the ADA, CDC and C-100 standards, the prevalence of bacterial contamination was estimated to be 85.0% (95% confidence interval (CI): 66.0-94.0%), 77.0% (95%CI: 66.0-85.0%) and 69.0% (95%CI: 67.0-71.0%), respectively. The prevalence of Legionella Pneumophila and Pseudomonas Aeruginosa in DUWLs was estimated to be 12.0% (95%CI: 10.0-14.0%) and 8.0% (95%CI: 2.0-24.0%), respectively.

CONCLUSION

The results of this review study suggested a high prevalence of bacterial biofilm in DUWLs; therefore, the use of appropriate disinfecting protocol is recommended to reduce the prevalence of contamination and reduce the probable cross-infection.

Contamination of dental unit water lines (DUWL) with Legionella pneumophila and Pseudomonas aeruginosa; A Middle East systematic review and meta-analysis

This review aimed to evaluate the contamination rate of dental unit waterlines (DUWL) with Pseudomonas aeruginosa and Legionella pneumophila in several countries in the Middle East.Literature search was conducted in databases such as PubMed, Scopus, Web of Science, and Google Scholar to gather studies published from the beginning of 2000 to 30th April 2020. Medical Subject Headings (MeSH) terms were; "Legionellosis"; "Legionnaire", "Legionellosis", "L. pneumophila", "dent", "dental", "dentistry", "Dental Unit Waterlines", "dental water", "DUWL", "Middle East", "P. aeruginosa", "Iran", "Turkey", "Iraq", and "Jordan". The search was independently conducted by two of the authors. Data was analyzed using Comprehensive Meta-Analysis software.Almost all studies included in this review reported a high rate of bacterial contamination of DUWL, which exceeded the current standard bacterial contamination level of <200 (CFU) mL-1 recommended by the American Dental Association (ADA). The combined prevalence of L. pneumophila from four countries (Iran, Jordan, Turkey, and Iraq) was 23.5% (95% Cl: 6.5-57.7), and the combined prevalence of P. aeruginosa was reported 21.7% (95% Cl: 7.1-50.1%).This study showed a high bacterial contamination rate of DUWL with opportunistic pathogens. So, it is recommended to prevent biofilm formation in DUWL, some measures should be extended by practical approaches allowing for water quality control and improvement on-site in the dental practices such as mobile filtration units, chlorination and disinfection chemicals.

Biofilm growth and microbial contamination of dental unit waterlines at Kuwait University dental center

Biofilm formation in dental unit waterlines and the resulting microbial contamination of the water in the system has become a significant problem. Contaminated water in the dental units is a major concern in dental clinics due to potential risk of causing infections particularly in elderly and immunocompromised patients. The aim of this study was at first to determine microbial contamination of the dental unit waterlines and then to study the efficacy of a comprehensive disinfection protocol on decreasing the microbial load. Water samples were collected before and after disinfection procedure from handpieces and water storage bottles from the dental units, a small 1-cm tubing was cut from each unit and subjected to microbiological culture on different growth media. Identification of the predominant species was achieved by 16S rRNA gene sequencing. Microbial growth was observed in samples collected from all dental units. Upon disinfection procedure, microbial contamination in the water samples and in the tubing surfaces was significantly reduced (P > 0.05). 16S rRNA gene sequencing revealed the presence of several species belonging to the genera Staphylococcus, Corynebacterium and Roseomonas, some of which are implicated in human infections. Aggravation of the biofilm growth on the tubing surfaces and the microbial contamination in the water can be effectively controlled by implementing appropriate and routine disinfection protocols. This may help protect the dental unit staff and the patients being exposed to the risk of infections.

Dental unit water content and antibiotic resistance of Pseudomonas aeruginosa and Pseudomonas species: a case study

Background

Many studies consider the contamination of dental unit waterlines (DUWLs), but few of them have studied the possible presence of antibiotic resistant Pseudomonas aeruginosa in the DUWLs.

Aims

Investigation of the presence of P. aeruginosa and Pseudomonas spp. strains in DUWLs and evaluation of their resistance to six antibiotics (ceftazidime, netilmicin, piperacillin/tazobactam, meropenem, levofloxacin, colistin sulfate) at a public dental clinic in Milan, Italy.

Results

Dental units were contaminated by P. aeruginosa with loads of 2–1,000 CFU/L and were mainly located on the mezzanine floor, with a range of 46–54%, while Pseudomonas spp. were primarily found on the first and second floors, ranging from 50 to 91%. P. aeruginosa was antibiotic resistant in 30% of the strains tested, andPseudomonas spp. in 31.8% . Cold water from controls was also contaminated by these microorganisms.

Conclusion

Monitoring antibiotic resistance in the water and adopting disinfection procedures on DUs are suggested within the Water Safety Plan.

Distinct Microbial Community of Accumulated Biofilm in Dental Unit Waterlines of Different Specialties

The contamination of dental unit waterlines (DUWLs) is a serious problem and directly affects the dental care. This study aims to explore the microbial community of biofilm in DUWL from different specialties and investigate the associated factors. A total of 36 biofilm samples from 18 DUWL of six specialties (i.e., prosthodontics, orthodontics, pediatrics, endodontics, oral surgery, and periodontics) at two time points (i.e., before and after daily dental practice) were collected with a novel method. Genomic DNA of samples was extracted, and then 16S ribosomal DNA (rDNA) (V3–V4 regions) and ITS2 gene were amplified and sequenced. Kruskal–Wallis and Wilcoxon rank test were adopted for statistical analysis. Microbial community with high diversity of bacteria (631 genera), fungi (193 genera), and viridiplantae was detected in the biofilm samples. Proteobacteria was the dominant bacteria (representing over 65.74–95.98% of the total sequences), and the dominant fungi was Ascomycota (93.9–99.3%). Microorganisms belonging to multiple genera involved in human diseases were detected including 25 genera of bacteria and eight genera of fungi, with relative abundance of six genera over 1% (i.e., Acinetobacter, Pseudomonas, Enterobacter, Aspergillus, Candida, and Penicillium). The biofilm microbiome may be influenced by the characteristics of dental specialty and routine work to some extent. The age of dental chair unit and overall number of patients had the strongest impact on the overall bacteria composition, and the effect of daily dental practices (associated with number of patients and dental specialty) on the fungi composition was the greatest. For the first time, biofilm in DUWL related to dental specialty was comprehensively evaluated, with more abundance of bacterial and fungal communities than in water samples. Biofilm accumulation with daily work and multiple kinds of opportunistic pathogen emphasized the infectious risk with dental care and the importance of biofilm control.

Evaluation of Hydrogen Peroxide and Cetylpyridinium Chloride as Bacterial Decontaminants of Dental Unit Water Lines at a Private Peruvian Dental School

Aim:

The aim of this study was to evaluate the hydrogen peroxide and cetylpyridinium chloride as bacterial decontaminants of dental unit water lines at a private Peruvian dental school.

Materials and Methods:

Water samples were obtained from 66 dental units of a University Dental Clinic before decontamination treatment and at days 3 and 7 thereafter. The biofilm treatments were applied equitably among the two treatment groups (n = 22) and one negative control (distilled water). The samples obtained on each collection day were taken to the biochemical laboratory in thermal boxes and then diluted, seeded, and incubated at 37°C for 24h to count colony forming units per milliliter (CFU/mL).

Results:

The samples to which hydrogen peroxide were applied had a mean of 1.53 × 10⁵ CFU/mL before application, 0.04 × 10⁵ CFU/mL at day 3, and 0.03 × 10⁵ CFU/mL at day 7, whereas the samples undergoing cetylpyridinium chloride treatment had a mean of 1.74 × 10⁵ CFU/mL before application, 615.38 CFU/mL on day 3, and 307.69 CFU/mL on day 7. Distilled water treatment showed a mean of 1.72 × 10⁵ ± 0.39 × 10⁵ CFU/mL at baseline, 1.51 × 10⁵ ± 1.40 × 10⁵ CFU/mL at day 3, and a mean of 1.74 × 10⁵ ± 0.47 × 10⁵ CFU/mL at day 7. Statistically significant differences were found among the three treatment groups at days 3 (P ≤ 0.001) and 7 (P ≤ 0.001) but not at baseline (P = 0.306).

Conclusions:

The antibacterial effect of cetylpyridinium chloride was significantly greater than that of hydrogen peroxide and distilled water, and can, therefore, be used for bacterial control in the water lines of dental units.

Patterns of antimicrobial resistance observed in the Middle East: Environmental and health care retrospectives

Antimicrobial resistance is one of the biggest worldwide challenging problems that associates with high morbidity and mortality rates. The resistance of bacteria to various antibiotic classes results in difficulties in the treatment of infectious diseases caused by those bacteria. This paper highlights and provides a critical overview of observational and experimental studies investigating the presence of antibiotic resistant bacteria in different environments in Middle East countries and the mechanisms by which bacteria acquire and spread resistance. The data of this research considered the published papers within the last ten years (2010-2020) and was carried out using PubMed. A total of 66 articles were selected in this review. This review covered studies done on antibiotic resistant bacteria found in a wide range of environments including foods, animals, groundwater, aquatic environments as well as industrial and hospital wastewater. They acquire and achieve their resistance through several mechanisms such as antibiotic resistant genes, efflux pumps and enzymatic reactions. However, the dissemination and spread of antibiotic resistant bacteria is affected by several factors like anthropogenic, domestic, inappropriate use of antibiotics and the expulsion of wastewater containing antibiotic residues to the environments. Therefore, it is important to increase the awareness regarding these activities and their effect on the environment and eventually on health.

Suction Hoses of Dental Units as a Potential Source of Microbial Contamination

OBJECTIVES

Dental units are necessary tools for modern dentistry. Microbial contamination of dental units is thought to be the result of biofilm formation in various parts of the unit. We aimed to identify the total microbial count in the suction hose of dental units, and detect the presence of Pseudomonas aeruginosa.

METHODS

Random sampling of suction hoses of dental units in Birjand, Iran, was performed in dental clinics on the first (n = 115) and last (n = 115) working days of the week. Total viable counts of bacteria and detection of P. aeruginosa were performed on plate count agar and cetrimide agar, respectively. Plates were incubated at 37 °C for 48 hours.

RESULTS

None of the samples were free from bacterial contamination. P. aeruginosa was detected in 22.6% and 18.3% of samples taken on the first and last working days, respectively.

CONCLUSIONS

Suction hoses were heavily contaminated with bacteria, especially opportunistic pathogens, and current disinfection does not adequately control the contamination.

Occurrence and biofilm forming ability of Pseudomonas aeruginosa in the water output of dental unit waterlines in a dental center in Alexandria, Egypt

Introduction

Dental unit waterlines (DUWLs) are notorious for being contaminated with different bacterial species including the opportunistic pathogen Pseudomonas aeruginosa which poses a risk to patients and professionals. This work aimed at studying the occurrence and biofilm-forming ability (BFA) of P. aeruginosa in the output of DUWLs in a dental center in Egypt.

Methods

Water samples were collected from the outlets of the high-speed hand piece, the air/water syringe and the cup filler waterlines. Bacteriological analysis included heterotrophic plate count (HPC), isolation and identification of P. aeruginosa and determination of the antimicrobial susceptibility and the BFA of the isolates by tissue culture plate (TCP) method and tube method (TM).

Results

The average concentration of HPC bacteria in the output of the 3 DUWLs was 2.9×10⁴ CFU/μL where 88.3% of the samples exceeded the Egyptian standards for drinking water (<50 CFU L). P. aeruginosa was isolated from nine cup filler samples (which had a water source different from the other waterlines). The isolates were sensitive to all tested antimicrobials. Of these nine isolates, 6, 5 and 4 were positive for BFA by TCP, modified TCP and TM, respectively.

Conclusions

More stringent measures are required to ensure safer dental water; as the majority of studied samples exceeded the required HPC bacterial limit and P. aeruginosa isolates were detected. P. aeruginosa isolates from DUWLs may not be as resistant to antibiotics as what is reported in the literature about clinical isolates. Some P. aeruginosa isolates can colonize DUWLs despite their inability to form biofilms in experimental testing.

Occupational risk for Legionella infection among dental healthcare workers: meta-analysis in occupational epidemiology

OBJECTIVE

The occupational risk for Legionella infection among dental healthcare workers (DHCWs) is conjectured because of the risk of routine inhalation of potentially contaminated aerosols produced by the dental instruments. Nevertheless, occupational epidemiology studies are contrasting. This meta-analysis assessed the level of scientific evidence regarding the relative occupational risk for Legionella infection among DHCWs.

METHODS

Literature search was performed without time and language restrictions, using broad data banks (PubMed, Scopus, Web of Science, GOOGLE Scholar) and generic keywords ('legionella' AND 'dent*'). Analytical cross-sectional studies comparing prevalence of high serum Legionella antibody levels in DHCWs and occupationally unexposed individuals were considered. The relative occupational risk was assessed through prevalence ratio (PR) with 95% CI. Between-study heterogeneity was assessed (Cochran's Q test) and was used to choose the meta-analytic method. Study quality (modified Newcastle-Ottawa Scale) and publication bias (Begg and Mazumdar's test, Egger and colleagues' test, trim and fill R₀ method) were assessed formally and considered for the sensitivity analysis. Sensitivity analysis to study inclusion, subgroup analyses (dental staff categories; publication year, before vs after 1998, ie, 5 years after the release by the Centers for Disease Control and Prevention of the infection control guidelines in dental healthcare setting) were performed.

RESULTS

Seven studies were included (2232 DHCWs, 1172 occupationally unexposed individuals). No evidence of publication bias was detected. The pooled PR estimate was statistically non-significant at 95% level (1.7; 95% CI 0.8 to 3.2), study-quality adjustment did not change the PR considerably (PR, 1.5; 95% CI 0.5 to 4.1). PR was statistically significant before 1998 and no longer significant after 1998. Subgroup analysis according to DHCW categories was inconclusive.

CONCLUSIONS

There is no scientific evidence that DHCWs are at high occupational risk. The differences between former and recent studies could be due to different characteristics of municipal water systems and the infection control guideline dissemination.

Microbial contamination of dental unit waterlines and effect on quality of indoor air

The microbiological quality in dental unit waterlines (DUWLs) is considered to be important because patients and dental staff with suppressed immune systems are regularly exposed to water and aerosols generated from dental units (DUs). Opportunistic pathogens like Pseudomonas, Legionella, Candida, and Aspergillus can be present in DUWLs, while during consultations, bioaerosols can be dispersed in the air, thus resulting in effects on microbiological quality of indoor air. This present study represents microbiological air and water quality in dental offices (DOs) and also concerns the relationship between the quality of DO air and dental unit water. This study aimed to assess both the microbial quality of dental unit water and the indoor air in 20 DOs and to survey the effect on the quality of the indoor air with the existing microorganisms in dental unit water. Fourteen out of 20 (70 %) DUWLs were found to be contaminated with a high number of aerobic mesophilic heterotrophic bacteria. In terms of bacterial air contamination levels, in 90 % of DOs, a medium level (<500 colony-forming units (CFU)/m(3)) of contamination was determined, while in terms of microfungal air contamination, in all DOs, a low level (<100 CFU/m(3)) of contamination was determined. Potential infection or allergen agents, such as Pseudomonas, Micrococcus, Staphylococcus, Alternaria, Cladosporium, Penicillium, Aspergillus, and Paecilomyces were isolated from water and air samples. This study's determination of contamination sources and evaluation of microbial load in DOs could contribute to the development of quality control methods in the future.