What the CDC Health Advisory on Dental Waterlines Means for the Orthodontic Practice

Alison Werner:

Hello, and welcome to the Orthodontic Products podcast on the MEDQOR Podcast Network. I am Alison Werner, Chief Editor of Orthodontic Products. And today I’m joined by infection prevention expert and consultant, Jackie Dorst, to talk about the CDC’s Health Alert Network health advisory regarding non-tuberculosis mycobacteria infections associated with contaminated dental unit waterlines, which was issued on Monday, October 31st.

Now Jackie is a long time contributor to Orthodontic Products. You may be familiar with our long-time series, In the Sterilization Room with Jackie, which aim to help orthodontic practitioners like you navigate the COVID-19 pandemic. For you that don’t know her, Jackie has been a consultant specializing in instrument sterilization, infection control and prevention in the dental setting for over 30 years. She has degrees in microbiology and dental hygiene, and has been a featured speaker at the American Dental Association and the American Association of Orthodontists. Jackie, great to be back with you again.

Jackie Dorst:

Thank you, Alison. It’s good to be with you. We’ve had a few sort of quiet months in relationship to the COVID-19 pandemic, so we’ve backed off a little bit on the In the Sterilization Room videos, but there are always new issues relating to infection control that are coming up. And this health advisory, this alert from CDC, is one that I think is going to be a significant importance for the orthodontic community.

Alison Werner:

Yeah, so let’s get started. These Health Alert advisories are rare, so why should orthodontic practices be paying attention to this?

Jackie Dorst:

Well, CDC put together the Health Alert advisories for the medical and dental communities when there were new infection control issues, infection prevention, maybe even on vaccines, that are a risk to the public health. And of course the most recent news that we’ve had on that was with monkeypox, and CDC had several of these health advisories relating to monkeypox. And fortunately, all of the health advisories helped to contain monkeypox. Those infections have leveled out now and it did not become a significant risk for the general population with it.

The one that was issued on October the 31st is a particular concern for me because this is not the first time that the dental community has had this type of infection. The non-tuberculosis mycobacterium infections were transmitted from contaminated water used in dental procedures in a pediatric dental office. And as CDC said, they were made aware in March of this year, 2022, of a cluster of infections that were in children who had been treated in a pediatric dental office.

There have been previous clusters of infections, and the first one was in Georgia in the Atlanta Metropolitan area in 2015. And at that time there were 24 pediatric dental patients who were identified at Children’s Hospital in the Atlanta area that had acquired infections when they went to the pediatric dental office and had a dental treatment procedure. Now these are serious infections caused by this mycobacterium, and it’s not the kind … Mycobacterium is a family of bacteria that includes tuberculosis, which causes a respiratory disease or infects the lungs. Mycobacterium is a large family of bacteria, so this is one of the genus, if you will, within this bacterium family that lives in water.

And after much research with the 2015 situation where these patients kept showing up at the hospital with lymphadenitis, now that’s an infection that came from their tooth, the tooth was infected, and moved into the lymph glands. And it can cause serious complications with it. Those serious complications can include anything from permanent tooth loss where the tooth had to be extracted afterwards, maybe even a nerve damage or a nerve facial palsy with it, fibrosis at the incision site, and then also some hearing loss with it. The antibiotics I should mention have to be … Most of the children had to be treated with IV antibiotics. It wasn’t just that they gave them a prescription of tablets and sent them home. They had to be hospitalized for maybe a week to 10 days with these IV antibiotics. And complications from the treatment can cause lifetime effects for these children.

So this was 2015 that the first infections were identified. And after much research by the Georgia Department of Health, and then they invited in the CDC when they couldn’t identify what was causing the infections, and then the experts came in. It was linked to the water. Water from the dental unit waterlines that goes through the high-speed handpieces to cool the high speed handpiece when the dentist is using that for treatment. Water that goes through our ultrasonic scalers, and water that goes through the air-water syringe.

Now the next cluster of infections happened in 2016, just one year after the Atlanta incident. And that was in Orange County, California. And again at a pediatric dental office, one pediatric dental office. And this time there was 71 patients infected.

Alison Werner:

Okay.

Jackie Dorst:

And again, when the health department comes in to inspect, the California Dental Board came in to inspect to identify what caused this cluster of infections, and then CDC invited in, it was again linked to the waterlines. And now here we are again in March of 2022, another cluster of infections. CDC has not released which site it is or how many patients are involved, because the investigation is still ongoing at this time. But we have children that are showing up.

So it was significant enough with these three incidences that CDC felt it was important to issue an advisory to the public and to the dental profession. And so every orthodontic office is going to probably receive questions from parents, from patients, about, “How safe is your water? Gee, I read or heard on the news or the media about these dental unit waterline infections. What do you do in your office?”

Alison Werner:

Right. Well, so that’s one of the reasons we really wanted to talk about this today is because this is likely to get picked up by the media in the coming weeks. What’s your advice to orthodontic practices about what they should be telling patients and parents, what should they have prepared on this?

Jackie Dorst:

Well, hopefully the orthodontic practice has been treating their water and testing their water to know that it is safe. And if they are doing that and they’ve had passed their test with under … And there’s a threshold on that. For nonsurgical procedures, their waterline should be under 500 colony forming units per milliliter, then they can easily share that information with their patients and tell them, “Yes, we do treat our waterlines with a healthcare approved antimicrobial agent and we test them for your safety. That’s one part of our infection control protocols with it.”

So they’re going to have questions, and they should be prepared on how to answer those questions.

Alison Werner:

Okay. Well, can you explain a little bit more about how dental unit waterlines are causing the spread of this disease?

Jackie Dorst:

Okay. This is a complex topic, and there are a number of resources for the orthodontist and maybe the clinical leader when they want to research it. But what happens with our orthodontic units is that water has to go through for us to use the air-water syringe. And the newer, more modern orthodontic units have what is called a water bottle attached to them, or referred to as a closed water system.

And when the water goes through those lines, in between patients the water is there and it’s stagnant. At the end of the day when we shut down the unit and it’s not used overnight, that stagnant water in those small lines is a great opportunity for microorganisms to grow and form what is called biofilm on the inside of the lines of the unit. And that biofilm can contain hundreds of microorganisms, and one of those is this microbacterium that can cause severe infection.

There’s Legionella and lots and lots of microorganisms, but normally non-infectious type microorganisms. So it’s that stagnant water. And let’s imagine, the average orthodontic office, they may work Monday through Thursday. At the end of the day on Thursday, they leave the office and shut down the orthodontic units and that water lays stagnant in the office through Friday, Saturday, Sunday. And that’s great time for that biofilm to build up in. And even in warmer summer months, they may even shut down the air conditioner and the temperatures are elevated in the office. Well, you add a little warmth and we all know how microorganisms love to grow in water. Any stagnant water can have that biofilm growing in there.

It’s an ongoing challenge that has to be managed on a daily, weekly, monthly basis to prevent biofilm from building up in the waterlines.

Alison Werner:

Okay. Let’s dive a little deeper into the proper protocol for dental unit waterlines. What should orthodontic practices know, in addition to what you’ve already said?

Jackie Dorst:

Well, if Alison, it comes down to three basic steps, and they’re basic, but each one is complicated on it. And first of all, they have to shock the lines. Shock like you shock a swimming pool. In a swimming pool you add extra chlorine to kill any overgrowth of algae or bacteria that are in the swimming pool. Well, you shock your lines with some sort of antimicrobial agent or cleaner, even bleach can do that, and that will kill the biofilm, and has a cleaner in it that will help remove the biofilm from inside the lines.

So now you’ve shocked them or cleaned the lines. Once you’ve done that, you add a healthcare antimicrobial agent that’s very low dose to the water that’s in the water bottle, and that will prevent the biofilm from building up in the future. Now anything that’s going to prevent microorganisms from growing has the potential to possibly be toxic to humans. So it needs to be a validated product that has been FDA approved and EPA approved that it’s safe for people using it.

And there are tablets that can be added to the water bottle. You have to know, is your water bottle one liter or two liters. Do you add one or two tablets? And normally those tablets will contain a very low dose of iodine or silver as the antimicrobial agent. There are also liquid drops that can be added that have another antimicrobial agent. And then the pickup tube that helps to bring the water out of the water bottle and go through the air-water syringe and into the handpieces can be replaced with an antimicrobial pickup tube, if you will, that has been impregnated with one of these antimicrobial agents.

Now you’ve shocked the lines, you’re treating them with an antimicrobial agent, but how do you know if it’s working? And that’s the third step, you have to test. You can test your water to see if you are under that threshold level of 500 colony forming units per milliliter of heterotrophic bacteria.

And that test can either be done where you take a sample of your water and send it off to a testing laboratory so you can have third party validation. Or you can do an in-office test using a sterile contained … It’s called a paddle system really because it has a membrane in it that will become like a Petri dish and grow any microorganisms in there. So you can do your own in-office test. It’s very similar to doing a spore test on an autoclave. We test our autoclave every week to see that it’s working, that we are operating it correctly and the gasket’s not leaking. And we can either do a mail-off spore test or we can do an in-office spore test.

So three steps. Shock to remove the biofilm, treat to prevent future biofilm from building up, and test to make certain or validate that everything you’re doing, the products are working, and you’re using the correct technique. And then you’ve got that documentation that yes, you have safe water coming out of your air-water syringe and your handpiece.

Alison Werner:

Okay. Jackie, I know in talking to you, dental unit waterline maintenance can be complex, especially depending on kind of the setup you have within your office. What’s your advice for orthodontic practices or what resources are available to know best practices or best setup, or just how to handle this if you’re feeling overwhelmed?

Jackie Dorst:

Alison, it really is a complex issue. And over the years I’ve had many orthodontic offices that have called me and said, “Oh, what do we do with this water bottle? We just bought new dental units.” Or, “We just built a new orthodontic office and now we have these water bottles and we don’t know what to do.”

There are a number of products out there and they have to be used correctly. And I’m going to give you an example. That shocking that I talked about, there are some products that if they’re not used correctly and the lines are not flushed properly, can actually cause bond failure. The residual product in the line can interfere with the orthodontic bonds in there. So it is very technique-sensitive.

One of the companies that I have relied on for recommending to my clients over the years, and that I feel gives excellent customer support along with great training videos, is ProEdge Dental. And it’s proedgedental.com. And if you can include maybe some of the resources in there. But if you go to their library page on proedgedental.com, there are a number of instructional videos that give the details on how to shock your waterlines, even using bleach with it. It’s a very technique-sensitive. You only leave the bleach in for 10 minutes, you must time it with it and be precise so that you don’t damage the equipment. But it’s a very effective way of removing biofilm.

They have a tutorial video on how to do shocking. They have tutorial videos on how to do the testing. Whether you’re doing in-office testing or whether you’re taking a sample in the sterile test tube that they provide, because again, that’s technique-sensitive. You take a water sample and imagine, here you’ve got to send it off to a laboratory. Well, the longer that water sits in there, if there are microorganisms, they could multiply. So you’ve got to ship it overnight in a cold pack, take the sterile sample so that you don’t recontaminate the sample with it, and you have to have a neutralizing agent in there that’s going to neutralize any of the antimicrobial agent that was in your water bottles.

Alison Werner:

Okay.

Jackie Dorst:

Again, it’s nice to know that you’ve got a company that will provide you with one-on-one coaching to help you get through that. And like I said, there are a lot of products out there, but I haven’t always found the companies that provide the support for this complex and technique-sensitive procedure for treating and testing the waterlines.

Alison Werner:

Okay. Well, thank you for that information. It really sounds like the takeaway here is that orthodontic practices should be paying attention to this alert. It could become a bigger story in terms of the media so they probably are likely to get questions, which means they need to be on top of their dental waterlines now, if they’re not already doing best practices. So yeah, thank you, Jackie, so much for this information.

Jackie Dorst:

Well, I would highly recommend that they download the OSAP, it’s O-S-A-P dot O-R-G white paper on dental unit waterlines. It was published in 2018. They can access it free, they don’t have to be a member of OSAP with it, and you can just go … Even if you just enter to the Google search “OSAP dental unit waterlines,” it’ll take you directly to that page. And then there are a number of other CDC publications on what’s the situation with dental unit waterlines.

If they need one-on-one coaching, because each orthodontic dental units are different, one from the other, whether you have a Ross unit or a Boyd unit. The configuration can be different, and some of them may even need to be retrofitted with water bottle lines. So if they need one-on-one coaching, how to set up your system and then how to do the three steps with it to shock, treat and test, I will schedule a one-on-one coaching webinar that we will look at their system and come up with what’s going to work for them.

Alison Werner:

Okay, great. And they can reach out to you at jackiedorst.com. That’s your website, correct?

Jackie Dorst:

Yes. Yes, they can.

Alison Werner:

Okay. And also, I know you had mentioned to me earlier that the ADA’s new book on infection … Is it Infection Control and … I’m forgetting the titles. [inaudible 00:19:20] a chapter.

Jackie Dorst:

Yes. The ADA, just within the last couple of months, has published a new comprehensive book on infection control, and it includes a lot of the pandemic updates even on controlling airborne disease transmission.

The title of that ADA book is Effective Infection Prevention and Control. It is available to ADA members. I believe the price is about $140 and it does have checklist with it. But again, sometimes with a new system and with new products to use, I know orthodontic team and dental team members like to have that over-the-shoulder coaching.

Alison Werner:

Oh yeah, absolutely.

Jackie Dorst:

Just like you and I … Yeah. When you put in a new software system or you upgrade your system, there are always issues that you go, “Ooh.” You’d really like to have somebody just get you through that one hurdle.

Alison Werner:

Exactly.

Jackie Dorst:

And it makes it so much more successful.

Alison Werner:

It’s so much easier to turn to an expert who already knows everything, who can guide you through step-by-step. So yes, so to our listeners, please reach out to Jackie if you have more questions and would like to get some expert advice on how to manage this and to ensure that your patients are safe. Jackie, thank you again so much for joining us today.

Jackie Dorst:

Alison, thank you and Orthodontic Products for sharing this timely information that affects our orthodontic profession and our patients.

Alison Werner:

Yeah, definitely.

Jackie Dorst:

We all want to provide safe orthodontic care for each patient.

Alison Werner:

Definitely. Well, to our listeners, be sure to subscribe to the MEDQOR Podcast Network to keep up with the latest Orthodontic Products podcasts. And check out orthodonticproductsonline.com to keep up with the latest orthodontic industry news. Until next time, take care.