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Buitrago JM, Kolbe RJ, Siqueira MF. Dental unit waterline testing practices: an 11-Year retrospective study. BMC Oral Health 2023; 23:867. [PMID: 37968643 PMCID: PMC10652605 DOI: 10.1186/s12903-023-03590-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/27/2023] [Indexed: 11/17/2023] Open
Abstract
OBJECTIVES This retrospective study examined the dental unit waterline (DUWL) testing practices of Saskatchewan dental clinics over a period of 11 years, with an emphasis on their responses after identification of high microbial levels. MATERIALS AND METHODS Dental clinics (n = 137) aseptically collected samples of output water from their air/water syringes, handpieces, and ultrasonic scaler lines using Sigma-Aldrich® waterline test kits and delivered them to a quality assurance laboratory. Tests were incubated for seven days at room temperature, and those with heterotrophic plate counts > 500 CFU/mL were reported as failures. Statistical analyses were performed on a database containing 4,093 test results. RESULTS Participating clinics submitted an average of 11 DUWL tests per year. Overall, 21% of tests failed, and a moderate positive association (rs=.52, p < 0.001) was found between clinics' DUWL testing frequency and failure rate. Only 7% of failed DUWL tests were followed up by collection of a subsequent test within two weeks, of which 47% still exceeded the 500 CFU/mL threshold. CONCLUSIONS Our findings demonstrate an association between DUWL testing frequency and detection of unacceptable microbial levels, along with infrequent retesting and often-inadequate intervention after a failed test. This suggests the need for further efforts at the regulatory and educational levels to maintain adequate water quality during dental treatment. CLINICAL RELEVANCE Procedural water can become contaminated in DUWLs and endanger patients. Regular DUWL monitoring and evidence-based interventions to treat contaminated systems are necessary to safeguard patient health.
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Affiliation(s)
- Juan M Buitrago
- College of Dentistry, University of Saskatchewan, Saskatoon, SK, Canada
| | - Rob J Kolbe
- College of Dentistry, University of Saskatchewan, Saskatoon, SK, Canada
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Petchphayaprai C, Chotipan C, Sa-Ngiampak P, Thotsaporn K, Ampornaramveth RS. Effectiveness of iodine for continuous decontamination of dental unit waterline. BDJ Open 2023; 9:34. [PMID: 37481614 PMCID: PMC10363156 DOI: 10.1038/s41405-023-00160-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/19/2023] [Accepted: 07/03/2023] [Indexed: 07/24/2023] Open
Abstract
OBJECTIVE Dental Unit Waterlines (DUWLs) are contaminated by various species of microorganisms. DUWLs should be disinfected appropriately to control microbial contamination. This study investigated the effectiveness of devices continuously releasing iodine to control microbial contamination in DUWLs. MATERIALS AND METHODS Ten dental chair units (DCU) at Chulalongkorn University were randomized into the iodine and control groups. After setting iodine treatment devices, the DCU was allowed to operate normally. 25 ml of water from airotors lines were collected weekly for enumerating bacteria. The viability of biofilms in DUWLs was quantified by ATP testing kit. The amount of iodine released into the procedural water was also quantified. RESULTS The continuous presence of iodine could significantly control bacterial contamination in the DUWL to be less than 500 CFU/mL, the standard level recommended by the Centre for Disease Control and Prevention (CDC). Iodine treatment can reduce bacterial CFU up to 98-100%. Biofilm viability in the iodine group was slightly lower than that of the control group though not statistically significant. After eleven months, the average iodine release was measured to be 3.6 ppm which is still effective in controlling bacterial contamination. CONCLUSION Continuously supplying iodine in DUWLs effectively controls microbial contamination.
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Affiliation(s)
- Chatchaya Petchphayaprai
- Center of Excellence on Oral Microbiology and Immunology, Department of Microbiology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Chutimon Chotipan
- Center of Excellence on Oral Microbiology and Immunology, Department of Microbiology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Pitchayapa Sa-Ngiampak
- Center of Excellence on Oral Microbiology and Immunology, Department of Microbiology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Kittisak Thotsaporn
- Department of Biochemistry, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand.
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Xing M, Zhang H, Zhang L, Qian W. Construction of ZnO/PCL Antibacterial Coating Potentially for Dental Unit Waterlines. J Funct Biomater 2023; 14:jfb14040225. [PMID: 37103315 PMCID: PMC10144832 DOI: 10.3390/jfb14040225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/04/2023] [Accepted: 04/13/2023] [Indexed: 04/28/2023] Open
Abstract
The formation of bacterial biofilms and the contamination of treatment water within dental unit waterlines can lead to a risk of secondary bacterial infections in immunocompromised patients. Although chemical disinfectants can reduce the contamination of treatment water, they can also cause corrosion damage to dental unit waterlines. Considering the antibacterial effect of ZnO, a ZnO-containing coating was prepared on the surface of polyurethane waterlines using polycaprolactone (PCL) with a good film-forming capacity. The ZnO-containing PCL coating improved the hydrophobicity of polyurethane waterlines, thus inhibiting the adhesion of bacteria. Moreover, the continuous slow release of Zn ions endowed polyurethane waterlines with antibacterial activity, thus effectively preventing the formation of bacterial biofilms. Meanwhile, the ZnO-containing PCL coating had good biocompatibility. The present study suggests that ZnO-containing PCL coating can realize a long-term antibacterial effect on the polyurethane waterlines by itself, providing a novel strategy for the manufacture of autonomous antibacterial dental unit waterlines.
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Affiliation(s)
- Min Xing
- Shanghai Xuhui District Dental Center, Shanghai 200032, China
| | - Haifeng Zhang
- State Key Laboratory of High Performance Ceramics and Superfine Microstructure, Shanghai Institute of Ceramics, Chinese Academy of Sciences, Shanghai 200050, China
| | - Ling Zhang
- Shanghai Xuhui District Dental Center, Shanghai 200032, China
| | - Wenhao Qian
- Shanghai Xuhui District Dental Center, Shanghai 200032, China
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Spagnolo AM, Sartini M, Cristina ML. Microbial Contamination of Dental Unit Waterlines and Potential Risk of Infection: A Narrative Review. Pathogens 2020; 9:E651. [PMID: 32823641 PMCID: PMC7460066 DOI: 10.3390/pathogens9080651] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/09/2020] [Accepted: 08/12/2020] [Indexed: 12/19/2022] Open
Abstract
Several studies have revealed that dental unit waterlines (DUWLs) are often contaminated by large numbers of various micro-organisms (bacteria, fungi, protozoa, viruses). Microbial contamination in DUWLs may originate from the mains water piped into the dental unit, the suck-back of patients' saliva into the line due to the lack of adequate valves, and contamination from bottled water systems. Some of the main determinants of microbial contamination in DUWLs are: a very small lumen size (0.5-2 mm) of the tubing used, high surface-to-volume ratio (6:1), low throughput and the materials of which the tubing is made, water stagnation outside of working hours. The environmental conditions present inside the conduits of the dental unit may facilitate the proliferation of micro-organisms and the consequent formation of biofilm on the interior surface of the pipes of DUWLs. During the use of handpieces, particularly high-speed rotating instruments, a spray is thrown up in the form of aerosols or spatters containing biological material (saliva, blood and dental plaque) and micro-organisms. This means that the health of both dental staff and patients could be at risk of infection. The risk of cross-infections in dental settings can be tackled by implementing combined interventions to prevent the contamination of DUWLs.
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Affiliation(s)
| | - Marina Sartini
- Department of Health Sciences, University of Genova, 16132 Genova, Italy; (A.M.S.); (M.L.C.)
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Zemouri C, de Soet JJ, Volgenant CMC, Crielaard W, Laheij AMGA. Heterogeneity in the efficacy of dental chemical disinfectants on water-derived biofilms in vitro. BIOFOULING 2020; 36:587-596. [PMID: 32580580 DOI: 10.1080/08927014.2020.1782894] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/29/2020] [Accepted: 06/08/2020] [Indexed: 06/11/2023]
Abstract
Conditions in dental unit waterlines are favourable for biofilm growth and contamination of dental unit water. The aim of this study was to assess the effect of several chemical disinfectants on bacteria in a biofilm model. Water-derived biofilms were grown in a static biofilm model (Amsterdam Active Attachment model), using two growth media. Biofilms were challenged with Alpron/Bilpron, Anoxyl, Citrisil, Dentosept, Green & Clean, ICX and Oxygenal in shock dose and maintenance doses. The concentration and the composition of the chemical disinfectants influenced the number of culturable bacteria in the biofilms. The application of a single shock dose followed by a low dose of the same chemical disinfectants resulted in the greatest suppression of viable bacteria in the biofilms. Exposure to Citrisil and ICX consistently resulted in failure to control the biofilms, while Alpron/Bilpron had a substantial and relevant effect on the number of bacteria in the biofilms.
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Affiliation(s)
- C Zemouri
- Department of Preventive Dentistry, Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - J J de Soet
- Department of Preventive Dentistry, Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - C M C Volgenant
- Department of Preventive Dentistry, Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - W Crielaard
- Department of Preventive Dentistry, Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - A M G A Laheij
- Department of Preventive Dentistry, Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
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Lizzadro J, Mazzotta M, Girolamini L, Dormi A, Pellati T, Cristino S. Comparison between Two Types of Dental Unit Waterlines: How Evaluation of Microbiological Contamination Can Support Risk Containment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E328. [PMID: 30682855 PMCID: PMC6388184 DOI: 10.3390/ijerph16030328] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/16/2019] [Accepted: 01/18/2019] [Indexed: 01/16/2023]
Abstract
Infection risk management in a dental unit waterline (DUWL) involves healthcare personnel and patients and is related to routine exposure to water and aerosols that may contain bacterial species. To improve water safety plans, maintenance, and sanitation procedures, analyses of heterotrophic plate counts (HPCs) at 36 °C, and two other microorganisms frequently associated with biofilms, Pseudomonas aeruginosa and Legionella spp., were performed in order to evaluate differences in microbiological contamination between two types of DUWLs: Type A, provided by a water tank, and Type B, directly connected to municipal water. The data showed that the water supply and water safety plan differentially influenced microbiological contamination: Type A DUWLs were more contaminated than Type B DUWLs for all microbiological parameters tested, with significant changes in the percentage of positive samples and contamination levels that were beyond the limits of standard guidelines. The results obtained show how the storage tank, the absence of anti-retraction valves, and the disinfection procedures performed are the main critical points of Type A DUWLs, which confirms that dental unit management (maintenance/sanitization) is often missed or not correctly applied by stakeholders, with an underestimation of the real risk of infection for patients and operators.
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Affiliation(s)
- Jessica Lizzadro
- Department of Biological, Geological, and Environmental Sciences, BiGeA, University of Bologna, via San Giacomo 12, 40126 Bologna, Italy.
| | - Marta Mazzotta
- Department of Biological, Geological, and Environmental Sciences, BiGeA, University of Bologna, via San Giacomo 12, 40126 Bologna, Italy.
| | - Luna Girolamini
- Department of Biological, Geological, and Environmental Sciences, BiGeA, University of Bologna, via San Giacomo 12, 40126 Bologna, Italy.
| | - Ada Dormi
- Department of Medical and Surgical Science, DIMEC, University of Bologna, via San Giacomo 12, 40126 Bologna, Italy.
| | - Tiziana Pellati
- GVM Care & Research, via Emaldi 10, 48124 Lugo di Ravenna, Italy.
| | - Sandra Cristino
- Department of Biological, Geological, and Environmental Sciences, BiGeA, University of Bologna, via San Giacomo 12, 40126 Bologna, Italy.
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Park CE, Jeong NY, Yang MJ, Kim HW, Joo SI, Kim KH, Seong HK, Hwang YY, Lim HM, Son JC, Yoon SH, Yoon NS, Jang IH. Study on the Standardization of a Surveillance Culture Laboratory in Infection Control Fields. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2018. [DOI: 10.15324/kjcls.2018.50.3.359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Chang-Eun Park
- Department of Biomedical Laboratory Science, Molecular Diagnostics Research Institute, Namseoul University, Cheonan, Korea
| | - Na-Yeon Jeong
- Infection Control Office, Samsung Medical Center, Seoul, Korea
| | - Min-Ji Yang
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Han-Wool Kim
- Infection Control Office, Pusan National University Hospital, Busan, Korea
| | - Sei-Ick Joo
- Department of Biomedical Laboratory Science, Daejeon University, Daejeon, Korea
| | - Keon-Han Kim
- Department of Laboratory Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Hee-Kyung Seong
- Department of Biomedical Laboratory Science, Dong-Eui Institute of Technology, Busan, Korea
| | - Yu-Yean Hwang
- Department of Laboratory Medicine, Samsung Medical Center, Seoul, Korea
| | - Hyun-Mi Lim
- Department of Laboratory Medicine, Soonchunhyang University Hospital, Seoul, Korea
| | - Jae-Cheol Son
- Department of Pulmonology, Chungbuk National University Hospital, Cheongju, Korea
| | | | - Nam-Seob Yoon
- Department of Laboratory Medicine, Asan Medical Center, Seoul, Korea
| | - In-Ho Jang
- Department of Biomedical Laboratory Science, SangJi University, Wonju, Korea
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Application of D-Amino Acids as Biofilm Dispersing Agent in Dental Unit Waterlines. Int J Dent 2018; 2018:9413925. [PMID: 29593796 PMCID: PMC5821966 DOI: 10.1155/2018/9413925] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/31/2017] [Accepted: 11/19/2017] [Indexed: 02/02/2023] Open
Abstract
Aim and Purpose Biofilms in dental unit waterlines (DUWLs) are extremely difficult to eliminate. Aim of this study is to evaluate the efficacy of a mixture of four D-amino acids on biofilm dispersion in DUWLs. Materials and Methods A mixture of four D-amino acids (D-methionine, D-tryptophan, D-leucine, and D-tyrosine, 10 mM each), distilled water (control), and 0.1 M hydrochloric acid (HCl) was used in the experiment. In laboratory, pieces of DUWLs covered with biofilms were submerged in different solutions for 5 days, flushed, and measured OD600 of the dispersed biofilms. Remnants of biofilms on the DUWLs were evaluated by SEM. In clinic, fifteen DCUs were incubated with test and control solutions, flushed, and measured OD600 of the dispersed biofilms. Microbial count of DUWL output water was enumerated twice a week for four weeks. Results There was a slight, but not significant, increase in OD600 of flushing water in D-amino acids group. D-amino acids effectively reduced bacterial plaque as demonstrated by SEM. Incubation with D-amino acids significantly reduced biofilms especially after the first day of flushing. Bacterial count in DUWL output water was significantly reduced after treatment with D-amino acids. Conclusion D-amino acids are applicable as biofilm dispersing agents in DUWLs.
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Ditommaso S, Giacomuzzi M, Ricciardi E, Zotti CM. Efficacy of a Low Dose of Hydrogen Peroxide (Peroxy Ag⁺) for Continuous Treatment of Dental Unit Water Lines: Challenge Test with Legionella pneumophila Serogroup 1 in a Simulated Dental Unit Waterline. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:E745. [PMID: 27455299 PMCID: PMC4962286 DOI: 10.3390/ijerph13070745] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 07/11/2016] [Accepted: 07/19/2016] [Indexed: 11/29/2022]
Abstract
This study was designed to examine the in vitro bactericidal activity of hydrogen peroxide against Legionella. We tested hydrogen peroxide (Peroxy Ag⁺) at 600 ppm to evaluate Legionella survival in a simulated dental treatment water system equipped with Water Hygienization Equipment (W.H.E.) device that was artificially contaminated. When Legionella pneumophila serogroup (sg) 1 was exposed to Peroxy Ag⁺ for 60 min we obtained a two decimal log reduction. High antimicrobial efficacy was obtained with extended periods of exposure: four decimal log reduction at 75 min and five decimal log reduction at 15 h of exposure. Involving a simulation device (Peroxy Ag⁺ is flushed into the simulation dental unit waterlines (DUWL)) we obtained an average reduction of 85% of Legionella load. The product is effective in reducing the number of Legionella cells after 75 min of contact time (99.997%) in the simulator device under test conditions. The Peroxy Ag⁺ treatment is safe for continuous use in the dental water supply system (i.e., it is safe for patient contact), so it could be used as a preventive option, and it may be useful in long-term treatments, alone or coupled with a daily or periodic shock treatment.
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Affiliation(s)
- Savina Ditommaso
- Department of Public Health and Pediatrics, University of Turin, Turin 10126, Italy.
| | - Monica Giacomuzzi
- Department of Public Health and Pediatrics, University of Turin, Turin 10126, Italy.
| | - Elisa Ricciardi
- Department of Public Health and Pediatrics, University of Turin, Turin 10126, Italy.
| | - Carla M Zotti
- Department of Public Health and Pediatrics, University of Turin, Turin 10126, Italy.
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Pawar A, Garg S, Mehta S, Dang R. Breaking the Chain of Infection: Dental Unit Water Quality Control. J Clin Diagn Res 2016; 10:ZC80-4. [PMID: 27630960 DOI: 10.7860/jcdr/2016/19070.8196] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 05/26/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The air-water syringes, ultrasonic scalers, high speed air turbine handpieces are connected to dental units by a network of small-bore plastic tubes through which water and air travel to activate or cool the instruments and it had been shown that this system is extensively contaminated with microbial biofilms and pose a potential risk of infection for patients as well as dental professionals. AIM To evaluate and compare the efficacy of various disinfectants in reducing the microbial colony count in water derived from Dental Unit Waterlines. MATERIALS AND METHODS Five random dental units were selected and samples were collected before and after intervention with 5 disinfectants (0.02% H2O2 continuously, 0.02% H2O2 continuously with shock treatment with 0.25% H2O2 weekly, 0.12% Chlorohexidine and 12% Ethanol overnight, 1:50 Original Listerine overnight, 2% Sodium Perborate and 2% EDTA 5 minutes in morning) using different disinfection methods for 4 weeks. Samples were cultured on Reasoner's 2A (R2A) agar for microbial counting. RESULTS Results were recorded as Colony forming units/ml (cfu/ml) and were evaluated statistically. Results showed that all the dental unit waterlines were heavily contaminated with microbes before any intervention. After 1 day of disinfection regime the counts reduced significantly and showed progressive reduction in consecutive weeks. Goals set by ADA & CDC were ultimately achieved at the end of 4 weeks. CONCLUSION All the disinfectants were equally effective in reducing the microbial colony count of DUWLs, irrespective of their concentration and method of disinfection.
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Affiliation(s)
- Amrita Pawar
- Senior Lecturer, Department of Prosthodontics, ITS College of Dental Sciences & Research , Muradnagar, Ghaziabad, UP, India
| | - Sandeep Garg
- Professor and Head, Department of Prosthodontics, MM College of Dental Sciences & Research , Mullana, Ambala, Haryana, India
| | - Sonia Mehta
- Associate Professor, Department of Microbiology, MM College of Medical Sciences & Research , Mullana, Ambala, Haryana, India
| | - Rajat Dang
- Professor, Department of Prosthodontics, MM College of Dental Sciences & Research , Mullana, Ambala, Haryana, India
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Oosthuysen J, Potgieter E, Fossey A. Compliance with infection prevention and control in oral health-care facilities: a global perspective. Int Dent J 2014; 64:297-311. [PMID: 25244364 DOI: 10.1111/idj.12134] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Many publications are available on the topic of compliance with infection prevention and control in oral health-care facilities all over the world. The approaches of developing and developed countries show wide variation, but the principles of infection prevention and control are the same globally. This study is a systematic review and global perspective of the available literature on infection prevention and control in oral health-care facilities. Nine focus areas on compliance with infection-control measures were investigated: knowledge of infectious occupational hazards; personal hygiene and care of hands; correct application of personal protective equipment; use of environmental barriers and disposable items; sterilisation (recirculation) of instruments and handpieces; disinfection (surfaces) and housekeeping; management of waste disposal; quality control of dental unit waterlines, biofilms and water; and some special considerations. Various international studies from developed countries have reported highly scientific evidence-based information. In developed countries, the resources for infection prevention and control are freely available, which is not the case in developing countries. The studies in developing countries also indicate serious shortcomings with regard to infection prevention and control knowledge and education in oral health-care facilities. This review highlights the fact that availability of resources will always be a challenge, but more so in developing countries. This presents unique challenges and the opportunity for innovative thinking to promote infection prevention and control.
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Affiliation(s)
- Jeanné Oosthuysen
- Department of Life Sciences, Central University of Technology, Free State, Bloemfontein, South Africa
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Samaranayake L. Memory and mnemonics. JOURNAL OF INVESTIGATIVE AND CLINICAL DENTISTRY 2012; 3:245-246. [PMID: 23129138 DOI: 10.1111/jicd.12014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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