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References

Blake G. The incidence and control of infection in dental spray reservoirs. Br Dent J. 1963; 115:412-416
Infection control recommendations for the dental office and the dental laboratory. J Am Dent Assoc. 1996; 127:672-680
Walker JT, Marsh PD. Microbial biofilm formation in DUWS and their control using disinfectants. J Dent. 2007; 35:721-730
Pankhurst CL, Coulter WA. Do contaminated dental unit water lines pose a risk of infection?. J Dent. 2007; 35:212-220
Barbot V, Robert A, Rodier M, Imbert C. Update on infectious risks associated with dental unit waterlines. FEMS Immunol Med Microbiol. 2012; 65:196-204
Ricci ML, Fontana S, Pinci F, Fiumana E, Pedna MF, Farolfi P Pneumonia associated with a dental unit waterline. Lancet. 2012; 379:(9816)
Greig JE, Carnie JA, Tallis GF, Ryan NJ, Tan AG, Gordon IR An outbreak of Legionnaires' disease at the Melbourne Aquarium, April 2000: investigation and case–control studies. Med J Aust. 2004; 180:566-572
Puttaiah R, Cederberg R. Assessment of endotoxin levels in dental effluent water. J Dent Res. 1998; 77
Putnins EE, Di Giovanni D, Bhullar AS. Dental unit waterline contamination and its possible implications during periodontal surgery. J Periodont. 2001; 72:393-400
Pankhurst CL, Coulter WA, Philpott-Howard JN, Surman-Lee S, Warburton F, Challacombe S. Evaluation of the potential risk of occupational asthma in dentists exposed to contaminated dental unit waterlines. Prim Dental Care. 2005; 12:53-59
Guidance on the Control and Prevention of Legionnaires' Disease in England. 2015;
European Centre for Disease Prevention and Control (ECDC). http://ecdc.europa.eu/en/publications/publications/legionnares-disease-europe-2014.pdf
Singh T, Coogan MM. Isolation of pathogenic Legionella species and Legionella-laden amoebae in dental unit waterlines. J Hosp Infect. 2005; 61:257-262
Pankhurst CL, Coulter WA, Philpott-Howard JJ, Harrison T, Warburton F, Platt S Prevalence of Legionellae waterline contamination and Legionella pneumophila antibodies in General Dental Practitioners in London and Rural Northern Ireland. Br Dent J. 2003; 195:591-594
Walker JT, Bradshaw DJ, Bennett AM, Fulford MR, Martin MV, Marsh PD. Microbial biofilm formation and contamination of dental-unit water systems in general practice. Appl Environ Microbiol. 2000; 66:3363-3367
Fotos PG, Westfall HN, Snyder IS, Miller RW, Mutchler BM. Prevalence of Legionella-specfic IgG and IgM antibody in a dental clinic population. J Dent Res. 1985; 64:1382-1385
Reinthaler FF, Mascher F, Stϋnzner D. Serological examinations for antibodies against Legionella species in dental personnel. J Dent Res. 1988; 67:942-943
Atlas RM, Williams JF, Huntington MK. Legionella contamination of dental-unit waters. Appl Environ Microbiol. 1995; 61:1208-1213
Schulze-Robbecke R, Feldman C, Fischeder R, Janning B, Exner M, Wahl G. Dental units: an environmental study of sources of potentially pathogenic mycobacteria. Tuber Lung Dis. 1995; 76:318-323
Martin MV The significance of the bacterial contamination of dental unit water systems. Br Dent J. 1987; 163:152-154
Health and Safety Executive. 2013. http://www.hse.gov.uk/pubns/books/hsg274.htm
Department of Health (England). Safe Water in Healthcare Premises. (HTM 04-01): Guidance on Design, Installation, Commissioning, Testing, Monitoring and Operation of Water Supply Systems in Healthcare Premises. 2016. http://www.gov.uk/government/publications/hot-and-cold-water-supply-storage-and-distribution-systems-for-healthcare-premises
Scottish Health Technical Memorandum 04-01: Water safety for healthcare premises Part A: Design, installation and testing.
Cobb CM, Martel CR, McKnight SA, Pasley-Mowray C, Ferguson BL, Williams K. How does time dependent dental unit waterline flushing affect planktonic bacteria?. J Dent Educ. 2002; 66:549-555
Berlutti F, Testarelli L, Vaia F, De Luca M, Dolci G. Efficacy of anti-retraction devices in preventing bacterial contamination of dental unit water lines. J Dent. 2003; 31:105-100
Coleman DC, O'Donnell MJ, Shore AC, Russell RJ. Biofilm problems in dental unit water systems and its practical control. J Appl Microbiol. 2009; 106:1424-1437
Schel AJ, Marsh PD, Bradshaw DJ, Finney M, Fulford MR, Frandsen E Comparison of the efficacies of disinfectants to control microbial contamination in dental unit water systems in general dental practices across the European Union. Appl Environ Microbiol. 2006; 72:1380-1387
Percival RS, Devine DA, Nattress B, Kite P, Marsh PD. Control of microbial contamination in dental unit water systems using tetra-sodium EDTA. J Appl Microbiol. 2009; 107:1081-1088
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Dental unit water lines and their disinfection and management: a review

From Volume 44, Issue 4, April 2017 | Pages 284-292

Authors

Caroline L Pankhurst

BSc, BDS, MSc, PhD, MRCPath(Specialist in Oral Microbiology)

Senior Specialist Clinical Teacher (part-time), King's College London Dental Institute, SAR China

Articles by Caroline L Pankhurst

Crispian Scully

CBE, DSc, DChD, DMed (HC), Dhc(multi), MD, PhD, PhD (HC), FMedSci, MDS, MRCS, BSc, FDS RCS, FDS RCPS, FFD RCSI, FDS RCSEd, FRCPath, FHEA

Bristol Dental Hospital, Lower Maudlin Street, Bristol BS1 2LY, UK

Articles by Crispian Scully

Lakshman Samaranayake

DSc, DDS, FRCPath, FHKCPath, FDS RCS(Edin), FRACDS, FDS RCPS

Professor Emeritus, and Immediate-past Dean, Faculty of Dentistry, University of Hong Kong

Articles by Lakshman Samaranayake

Email Lakshman Samaranayake

Abstract

The perceived threat to public health from dental unit water line (DUWL) contamination comes from opportunistic and respiratory pathogens such as Legionella spp, Nontuberculous Mycobacteria (NTM) and pseudomonads. These organisms can grow and multiply in the DUWL biofilm to reach infective concentrations, with the potential for inhalation leading to respiratory infections or direct contamination of surgical wounds. In this paper we discuss current legislation and practical methods for delivering water within the DUWL that meets the standards for safety.

CPD/Clinical Relevance: Understanding the clinical relevance and methods for decontaminating DUWL is essential to create a safe working environment in dentistry.

Article

It was first recognized in the 1960s that water sampled from the DUWL contained large numbers of organisms in the range 104–106 colony forming units (cfu)/mL.1

Two decades later the American Dental Association (ADA) set the goal of <200 cfu/mL of aerobic heterotrophs as the standard for dental unit water lines.2 This figure is reflected in the current recommendation for England, Wales and Northern Ireland for dental unit water quality of 100–200 cfu/mL of aerobic heterotrophs at 22°C.3 Since then, our understanding of the physiology of the biofilm,4 incidence data on legionellae in dental practice5,6 and the first proven case of Legionella transmission and death of a patient associated with contaminated DUWLs have transformed the management of DUWLs.7 Challenges caused by Legionella contamination have not just affected dentistry but, around the world, there have been major outbreaks of Legionnaires' disease with resultant deaths of many of those infected.8 Indeed, dentistry is specifically included in the Approved Code of Practice for Legionnaires' disease control in water systems, which states that DUWL management is viewed in the context of the dental practice's overall hot and cold water supply systems.9

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