Water, water everywhere but not a drop to drink?

Evaluation of effect of three different dental unit waterline antimicrobials on the shear bond strength to dentin - An ex vivo study

BACKGROUND

In restorative treatment dental unit water is used while irrigating the cavity and also in the use of composite restorations to flush away the etchant to place bonding agent. These antimicrobials may influence the bond strength of the dentine bonding agent to the dentine.

AIM AND OBJECTIVE

To evaluate the effect of three different dental units waterline antimicrobials on the shear bond strength of dentin.

MATERIALS AND METHODS

Sixty freshly extracted human teeth were taken and the occlusal surfaces were sectioned to obtain a flat dentin surface. Then the teeth were randomized into 4 groups depending on the antimicrobial used: Group 1(Distilled water), Group 2 (Alpron), Group 3 (CitriSil), and Group 4 (Chlorhexidine). The dentine surface was prepared for bonding and composite resin was placed in two increments of 2 mm each. The specimens were stored in distilled water, thermo cycled after 7 days shear test was performed by using the universal testing machine.

RESULT

No significant difference between Group 1 and Group 2 with regard to shear bond strength. There was a significant difference in the SBS of Group 1 and Group 3 and Group 4. The SBS of group 2 was higher than Group 3 and Group 4 and the difference was statistically significant.

CONCLUSION

Citrisil and Chlorhexidine groups showed affected bond strength whereas Alpron did not vary with bond strength.

Effect of biocides on biofilm bacteria from dental unit water lines

Microbial biofilm formation in dental unit water lines (DUWL) is a phenomenon that has been recognized for nearly four decades. Water delivered by DUWL can harbor high numbers of bacteria, including opportunistic pathogens. Biofilms on tubing within DUWL may serve as a reservoir for these microorganisms and should therefore be controlled. In this study, the effects of eight biocides were monitored on DUWL biofilms individually and in combination by epifluorescence microscopy and total viable counts (TVC). The effects of sodium dodecyl sulphate (SDS), hydrogen peroxide (H2O2), sodium hypochlorite (NaOCl), phenol (Phe), Tween 20 (Tw 20), ethylenediaminetetraacetic acid (EDTA), chlorohexidine gluconate (CHX), and povidine iodine (PI) were tested on DUWL biofilms alone and in combination. PI was found to have negligible effects on biofilm removal either applied alone or in combined form with CHX. Applying all biocides simultaneously did not completely eliminate viable bacteria nor did they remove biofilm. Overall, when combined, the biocides performed better than singly applied products. The most effective biocides were NaOCl and Phe (both alone and in combination).

Attitudes of general dental practitioners in Europe to the microbial risk associated with dental unit water systems

Dental Unit Water Systems (DUWS) are used in dental practices to provide water for cooling of dental equipment and irrigation of the oral cavity. However, they have been demonstrated to be contaminated with micro-organisms. There are currently no European Union (EU) Commission guidelines for the microbial quality of water discharged by DUWS. This study was part of an EU research programme to investigate the microbial contamination of DUWS in general dental practice (GDP) in the UK, Denmark, Germany, The Netherlands, Ireland, Greece and Spain.

OBJECTIVE

To undertake a questionnaire survey on the type of DUWS in use and determine the attitude of GDPs to the risk of microbial infection from DUWS.

MATERIALS AND METHODS

The questionnaire was written and translated into the language of each country before being posted to each participating dentist. Dentists were asked to complete the questionnaire survey and return it by post.

RESULTS AND CONCLUSIONS

The major findings were that the majority of dentists did not clean, disinfect or determine the microbial load of their DUWS, and that dentists would welcome regular monitoring and advice on maintaining their DUWS; the introduction of guidelines; and recommendations on controlling the microbial load of DUWS.

Comparison of the efficacies of disinfectants to control microbial contamination in dental unit water systems in general dental practices across the European Union

Water delivered by dental unit water systems (DUWS) in general dental practices can harbor high numbers of bacteria, including opportunistic pathogens. Biofilms on tubing within DUWS provide a reservoir for microorganisms and should be controlled. This study compared disinfection products for their ability to meet the American Dental Association's guideline of <200 CFU x ml(-1) for DUWS water. Alpron, BioBlue, Dentosept, Oxygenal, Sanosil, Sterilex Ultra, and Ster4Spray were tested in DUWS (n = 134) in Denmark, Germany, Greece, Ireland, The Netherlands, Spain, and the United Kingdom. Weekly water samples were tested for total viable counts (TVCs) on yeast extract agar, and, where possible, the effects of products on established biofilm (TVCs) were measured. A 4- to 5-week baseline measurement period was followed by 6 to 8 weeks of disinfection (intermittent or continuous product application). DUWS water TVCs before disinfection ranged from 0 to 5.41 log CFU x ml(-1). Disinfectants achieved reductions in the median water TVC ranging from 0.69 (Ster4Spray) to 3.11 (Dentosept) log CFU x ml(-1), although occasional high values (up to 4.88 log CFU x ml(-1)) occurred with all products. Before treatment, 64% of all baseline samples exceeded American Dental Association guidelines, compared to only 17% following commencement of treatment; where tested, biofilm TVCs were reduced to below detectable levels. The antimicrobial efficacies of products varied (e.g., 91% of water samples from DUWS treated with Dentosept or Oxygenal met American Dental Association guidelines, compared to 60% of those treated with Ster4Spray). Overall, the continuously applied products performed better than those applied intermittently. The most effective products were Dentosept and Oxygenal, although Dentosept gave the most consistent and sustained antimicrobial effect over time.

An investigation of the efficacy of super–oxidised (Optident/Sterilox) water for the disinfection of dental unit water lines

AIMS

To determine the efficacy of super-oxidised water (Optident/Sterilox) in the decontamination of dental unit water lines.

METHODS

Dental units (10) were first purged with concentrated super-oxidised water. After purging, a 5% (v/v) super-oxidised water was used as a maintenance dose. Samples for microbiology were taken after 0,1,2,3,4,5,6,7 d, and each week for a further 13 weeks.

RESULTS

After purging, 5% (v/v) super-oxidised water was successful in reducing the microbial counts to zero, although in three of the units some bacteria were intermittently isolated in the first week of treatment.

CONCLUSIONS

Super-oxidised water was successful in the removal of bacteria from dental unit water supplies. Complete removal required the treatment with a purge phase of concentrated disinfectant and a maintenance phase of at least two weeks.

Water ecology of Legionella and protozoan: environmental and public health perspectives

Ecological studies on Legionella spp. are essential to better understand their sources in the natural environments, the mechanism of their entry into man-made water systems and the factors enabling their survival and growth in aquatic habitats. Legionella spp. exhibits peculiar and multiple strategies to adapt to stressful environment conditions which normally impair other germ survival. These strategies include the ability to enter in a viable but non-cultivable (VBNC) state, to multiply intracellularly within a variety of protozoa, such as amoebae, to survive as free organisms within biofilms and to be enhanced/inhibited by the presence of other aquatic bacteria. The host-parasite interaction has been shown to be central in the pathogenesis and ecology of L. pneumophila. The bacterial-protozoan interaction contributes to the amplification of Legionella population in water systems, represents a shelter against unfavourable environmental conditions, acts as a reservoir of infection and contributes to virulence by priming the pathogen to infect human cells. Legionella is able to survive as free organism for long periods within biofilms which are widespread in man-made water systems. Biofilm provides shelter and nutrients, exhibits a remarkable resistance to biocide compounds and chlorination, thus representing ecological niches for legionella persistence in such environments. Further knowledge on biofilm-associated legionellae may lead to effective control measures to prevent legionellosis. Lastly, new perspectives in controlling legionella contamination can arise from investigations on aquatic bacteria able to inhibit legionella growth in natural and artificial water systems.

An investigation of the microbial contamination of dental unit air and water lines

AIM

The objective of this study was to measure the microbial contamination released from dental unit air lines (DUAL) and dental unit water lines (DUWL).

MATERIALS AND METHODS

Emissions from DUAL and DUWL from five dental units supplied by a central water source (tap) and a centralised air supply were sampled three times over a five- week period. Air was forced through sterile water and then plated onto selective agar using apparatus designed to spread the sample solution evenly, and then incubated at room temperature for seven days. Colonies were then counted and the concentration of bacteria present was determined and expressed as colony forming units per millilitre (cfu/ml) per minute. The same procedure was used to evaluate five other dental units, which had attached independent water reservoir (bottle) systems (IWR). Only deionised water was added to the bottles and unit waterlines were cleaned weekly with alkaline peroxide based solution. Values were expressed as cfu/ml.

RESULTS

Air and water specimens obtained from dental units supplied with tap water had microbial counts significantly (t-test, p < 0.05) greater than IWR dental units.

CONCLUSIONS

Results indicate that IWR can reduce the numbers of micro-organisms released from DUWL. However, the effectiveness of such systems should be routinely monitored. Emissions from DUAL seems to reflect the levels of microbial contamination present in DUWL.

A between-patient disinfection method to control water line contamination and biofilm inside dental units

The aim of the present study was to evaluate the efficacy of a between-patient disinfection procedures to maintain low bacterial counts in dental unit water line (DUWL) effluents, and control dental water line biofilms. Six dental units already in use, that had never been cleaned, were monitored for three weeks. During the first week only baseline contamination levels were assessed with no treatment of the system. In the second week lines were flushed with water for 30 s before treating each patient. During the third week, a disinfection procedure with 0.26% peracetic acid, followed by a water flush, was implemented before treating each patient. DUWL samples were collected both at the beginning and at the end of 216 dental procedures (72 during each period), plated on R2A agar and incubated at room temperature for seven days to obtain total bacterial counts in colony forming units per millilitre. To assess biofilm control, nine dental units (five never used and four old dental units with established biofilm) were used for 30 days in routine dental practice undergoing five between-patient DUWL disinfecting cycles every day. Water line samples were removed at baseline and at the end of the study and examined by scanning electron microscopy to determine the presence or absence of biofilms. A significant difference (P < 0.01) in mean DUWL bacterial counts was found between the three sets of observations. Biofilms were not present in any of the new dental units and a demonstrable reduction in the biofilms from the four dental units with previous presence of established biofilms was observed at the end of the study. In this study, a between-patient disinfection procedure consisting of flushing DUWL with peracetic acid with use of water was efficacious in the control of both microbial contamination of dental treatment water and dental water line biofilms.

Total viable counts, ATP, and endotoxin levels as potential markers of microbial contamination of dental unit water systems

OBJECTIVES

To determine if either ATP or endotoxin concentrations in water supplied by dental unit water systems (DUWS) correlated with total viable counts (TVC), and therefore could be used as a rapid, chairside measure of levels of microbial contamination.

DESIGN

A prospective trial.

METHOD

Fifty-seven water samples were taken from the 'triple spray', air rotor and source water supplies from 25 dental units in eight practices. The samples were assayed for endotoxin concentration, total ATP and TVC. A pilot study was performed to assess the relationship between TVC and total cell counts, as determined by flow cytometry.

RESULTS

ATP concentrations ranged from 22 to 958 relative light units (RLU) and free endotoxin ranged from 25 to 600 EU ml(-1). TVC varied from not detected to 2.16 x 10(4) CFU ml(-1). The ATP method proved to be a simple and rapid method that could be used at the chairside. However, there was no correlation between ATP or endotoxin concentrations and TVC in DUWS. TVC generally underestimated the total cell count by 50 to 500 fold.

CONCLUSION

Half of the water samples from DUWS exceeded recommended levels of TVC. However, ATP and endotoxin concentrations in DUWS water samples did not correlate with these TVC data and therefore could not be recommended as an alternative assay to TVC for measuring bacterial contamination or for monitoring water treatment efficacy.

Microbiological evaluation of a range of disinfectant products to control mixed-species biofilm contamination in a laboratory model of a dental unit water system

Dental unit water system (DUWS) tubing harbors complex multispecies biofilms that are responsible for high microbial levels at the distal outlet. The aim of this study was to use an established biofilm laboratory model to simulate biofouling of DUWS to evaluate practical, cost-effective, and evidence-based methods of microbial decontamination. Reproducible biofilms were developed in the model over 14 days; decontamination was assessed using total viable counts (TVC) and microscopic-image analysis techniques to view the inner surface of tubing. Flushing did not reduce the biofilm coverage or TVC. Combizyme and ozone did not completely eliminate the viable bacteria (70 and 65% reduction in biofilm TVC, respectively), nor did they remove the biofilm (45 and 57% reduction in biofilm coverage, respectively). Chlorhexidine and Bio2000 (active agent: ethanol and chlorhexidine), Tegodor and Gigasept Rapid (aldehyde based), and Grotanol (hydroxide based) completely eliminated the TVC but did not completely remove biofilm (31, 53 33, 34, and 64.9% reduction of biofilm coverage, respectively). Other products including Grotanol Flussig (phenol based), Betadine (povidone-iodine based), Alpron (chlorite based), and the hydroxide-containing products Sporklenz, Sterilex Ultra, Dialox, Sterilox, Sanosil, Oxigenal, and Grotanat Bohrerbad resulted in a 100% reduction in the biofilm TVC and a >95% reduction in biofilm coverage. The study demonstrated that while many disinfectants achieve a sufficient reduction in TVC they may not necessarily remove unwanted biofilm from the tubing surfaces as tested in this laboratory-controlled biofilm model.

A new chemical formulation for control of dental unit water line contamination: An 'in vitro' and clinical 'study'

BACKGROUND: Water delivered by dental units during routine dental practice is highly contaminated. The aim of this study is to evaluate the efficacy of a new chemical solution flushed through Dental Unit Water Lines (DUWL) for the control of contamination inside dental units. MATERIALS AND METHODS: Six old dental units equipped with a device designed to automatically flush disinfecting solutions through the water system (Castellini Autosteril) were selected. Water samples from DUWL effluents were collected in each dental unit for 10 randomly selected days, before and after a 5 minute DUWL disinfecting cycle with TetraAcetylEthileneDiamine (TAED) and persalt (Ster4spray produced by Farmec spa, and distributed by Castellini spa). Water samples were plated in R2A Agar and cultured at room temperature for 7 days, and the total number of heterotrophic microorganisms counted and expressed in Log10 CFU/mL A general linear model was fitted and multiple regression ANOVA for repeated measures was used for the statistical analysis. RESULTS: The mean contamination in DUWL effluent at baseline was 5.45 &#PlusMinus; 0.35 CFU/mL (range 4.79 to 5.93 CFU/mL). When water samples were tested "in vitro" against the chemical, no growth of heterotrophic bacteria was detected after a 5 minute contact in any of the water samples tested. After undergoing a 5 minute disinfecting cycle with the chemical, DUWL mean contamination in water effluents was 2.01 &#PlusMinus; 0.32 CFU/mL (range 1.30 to 2.74 CFU/mL) (significant difference with respect to baseline). CONCLUSIONS: An inbetween patient disinfecting procedure consisting of flushing DUWL with TAED and persalt equivalent to 0.26% peracetic acid could be useful in routine dental practice for cross-contamination control.

Microbial biofilm formation and contamination of dental-unit water systems in general dental practice

Dental-unit water systems (DUWS) harbor bacterial biofilms, which may serve as a haven for pathogens. The aim of this study was to investigate the microbial load of water from DUWS in general dental practices and the biofouling of DUWS tubing. Water and tube samples were taken from 55 dental surgeries in southwestern England. Contamination was determined by viable counts on environmentally selective, clinically selective, and pathogen-selective media, and biofouling was determined by using microscopic and image analysis techniques. Microbial loading ranged from 500 to 10(5) CFU. ml(-1); in 95% of DUWS water samples, it exceeded European Union drinking water guidelines and in 83% it exceeded American Dental Association DUWS standards. Among visible bacteria, 68% were viable by BacLight staining, but only 5% of this "viable by BacLight" fraction produced colonies on agar plates. Legionella pneumophila, Mycobacterium spp., Candida spp., and Pseudomonas spp. were detected in one, five, two, and nine different surgeries, respectively. Presumptive oral streptococci and Fusobacterium spp. were detected in four and one surgeries, respectively, suggesting back siphonage and failure of antiretraction devices. Hepatitis B virus was never detected. Decontamination strategies (5 of 55 surgeries) significantly reduced biofilm coverage but significantly increased microbial numbers in the water phase (in both cases, P < 0.05). Microbial loads were not significantly different in DUWS fed with soft, hard, deionized, or distilled water or in different DUWS (main, tank, or bottle fed). Microbiologically, no DUWS can be considered "cleaner" than others. DUWS deliver water to patients with microbial levels exceeding those considered safe for drinking water.