How does current policy in dentistry impact waterline disinfection

(1361 words) Nov 2024.

How does current policy in dentistry impact waterline disinfection 

Dental decon leads have long recognised the risks of biofilm accumulation in dental waterlines. This article aims to inform and clarify current legislation and guidance governing dental practice water lines.  

Current policies in dentistry, particularly in countries like the UK, have a significant impact on how dental practices manage and disinfect their waterlines. These policies are shaped by regulatory bodies such as the Care Quality Commission (CQC), National Health Service (NHS), Health and Safety Executive (HSE), and international guidelines from organizations like the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). They aim to prevent waterborne infections, ensure safe patient care, and maintain high standards of infection control. 

Regulatory Oversight 

  • Care Quality Commission (CQC) Standards: In the UK, the CQC plays a major role in ensuring dental practices adhere to infection control protocols, including waterline disinfection. Practices are required to meet CQC standards1 for hygiene and safety, and waterline disinfection is part of the broader infection control inspections. Failure to comply can result in warnings, penalties, or even closure. 
  • Mandatory Water Quality Standards: Policies require dental practices to ensure that water used in patient procedures contains no more than 200 colony-forming units (CFU) of bacteria per ml of water, aligning with potable drinking water standards. This mandate encourages the regular use of disinfection protocols to keep waterlines within safe microbial limits. 
  • European Drinking Water Directive (2020): The Directive 98/83/EC lays down the parameters for the quality of water intended for human consumption which includes healthcare institutions, states; “water intended for human consumption is free from any micro-organisms and parasites and from any substances which, in numbers or concentrations, in certain cases, constitute a potential danger to human health, and that it meets those minimum requirements.”   

Guidelines for Disinfection Procedures 

  • Daily Flushing and Disinfection: HTM 01-05: Decontamination in primary care dental practice guidelines recommend that dental units be flushed with water at the start of each day and between patients for at least 2 minutes and for 20-30 seconds between each patient. Policies from bodies such as the Department of Health and Social Care (DHSC) and NHS infection control guidelines2 also emphasize the importance of daily disinfection to prevent the buildup of biofilm in waterlines. 
  • Periodic Shock Treatments: Policies also recommend periodic “shock” disinfection, where stronger chemicals are used to clean out biofilms that may develop despite routine flushing. This ensures that more stubborn or long-term biofilm deposits are removed from waterlines. 
  • Best practice: For the control of Legionella, ‘The control of legionella bacteria in water systems: Code of Practice and guidance,’ L8 and advises at-risk systems including those with the patient should be drained at the end of each day. This code is particularly important as any breach can legally enforced by prosecution. 

Disinfectant Use 

  • Approved Chemicals and Systems: Ensure the correct use of specific chemical agents that are proven to be effective in waterline disinfection, such as hydrogen peroxide, chlorine dioxide5, hypochlorous4 and other antimicrobial agents. Dental practices are encouraged or required to use only products which meet the specific regulatory standards for efficacy and safety. For medical devices this is a CE mark and for disinfectants, Biocides Article 95. 

Routine Microbial Testing and Monitoring 

  • Routine Waterline Testing: Current best practice recommends regular microbial testing of dental waterlines. Practices are expected to periodically test their water for bacterial load and ensure it meets the required safety standards. This testing may be performed in-house or outsourced to external labs, and the results must be documented and available for inspection during audits. 
  • Documentation and Record-Keeping: Policies mandate that dental practices maintain records of waterline testing, disinfection procedures, and maintenance activities. These records are reviewed during inspections, and failure to provide them can result in regulatory action. This encourages consistent monitoring and adherence to disinfection schedules. 

COVID-19 Impact and Aerosol Concerns 

  • Enhanced Disinfection Protocols: The COVID-19 pandemic highlighted the need for stricter infection control measures, particularly regarding aerosol-generating procedures (AGPs), which can expose patients and staff to airborne contaminants7. As waterlines are often involved in these procedures, policies have been updated to emphasize the importance of thoroughly disinfecting waterlines to prevent contamination from aerosolized water droplets 10. 
  • Increased Frequency of Disinfection: During the pandemic, dental practices were required to enhance their disinfection protocols, including more frequent and thorough waterline cleaning, to reduce the risk of cross-infection. These stricter protocols remain in place in many practices as part of post-pandemic safety measures. 

Staff Training and Education 

  • Mandatory Staff Training: Regular training ensures that staff understand how to use disinfection products correctly, adhere to disinfection schedules, and monitor water quality effectively. 
  • Continuing Professional Development (CPD): Dental professionals must engage in ongoing CPD. Practice policies encourage dental practitioners to keep up with the latest research, technology, and guidelines for waterline disinfection, reinforcing good practices. 

Compliance with European and International Standards 

  • European Standards (EN 1717:2000): In the UK, dental practices must comply with European water safety and disinfection standards. These standards dictate how waterlines should be managed and disinfected to prevent contamination from backflow and cross-connections, ensuring that water used in dental procedures is safe. 
  • CDC and WHO Guidelines: Although not legally binding in the UK, CDC and WHO guidelines have a significant influence on UK policies. These organizations provide comprehensive recommendations for maintaining safe waterlines in dental practices, and UK regulatory bodies often incorporate these best practices into their own frameworks. 

Cost and Accessibility Implications 

  • Cost of Compliance: While current policies improve waterline safety, they also increase operational costs for dental practices. Disinfectants, microbial testing, and automated treatment systems can be expensive, especially for smaller or rural practices. However, these costs are seen as necessary to meet the minimum safety standards required by law. 
  • Accessibility of Advanced Solutions: Some smaller or under-resourced dental practices may struggle to adopt advanced disinfection systems (such as continuous waterline treatment devices) due to cost constraints.  

Patient Safety and Public Health 

  • Focus on Patient Safety: Policies emphasize patient safety, ensuring that dental water used in procedures does not introduce harmful bacteria or pathogens. This aligns with broader public health goals of preventing waterborne infections in healthcare settings. 
  • Patient Communication: In response to regulatory changes, some practices now openly communicate with patients about their infection control measures, including how they disinfect waterlines. This transparency builds trust and helps reassure patients that the practice is following the highest standards of care. 

Technological Advances and Innovation 

  • New Technology: Current policies support the adoption of new and advanced disinfection technologies, such as UV disinfection8, silver ionization9, and automated dosing systems. By encouraging practices to invest in these technologies, policies help ensure more effective and consistent waterline disinfection based on emerging research in microbiology and infection control.  

Conclusion 

Current dental policies in the UK and elsewhere have a significant impact on how waterlines are managed and disinfected. These policies enforce strict guidelines for microbial testing, chemical use, routine maintenance, and staff training, all of which contribute to maintaining clean and safe dental unit waterlines. While compliance might appear like they increase operational costs for practices, the overall goal of these policies is to protect patient and staff safety by reducing the risk of waterborne infections. The ongoing adaptation of these policies based on new research and technology ensures that waterline disinfection remains a key focus in modern dentistry.  

Solution 

Left untreated biofilm can accumulate in dental unit waterlines where the pathogenic organisms then disperse through the water network posing a risk to the dentist, dental team, and patients.  

CleanCert is a convenient, sustainable and highly effective waterline disinfectant, used to disinfect and maintain dental chair waterlines and equipment. CleanCert is the only product that contains both a waterline cleaner and biofilm remover in one bottle whilst being 100% eco-friendly.  

CleanCert waterline disinfectant contains hypochlorous acid, a naturally occurring substance with antimicrobial action which is recognised as one of the most powerful biofilms eliminating molecules. It is non-toxic, pH neutral and 100% biodegradable reducing the risk of environmental contamination through dental waste disposal. 

Simon Davies is founder and Commercial Director of Tec Safe, a dental company that specialises in developing easier and safer decontamination products for a wide variety of dental applications, using eco-friendly solutions. 

Visit the website: www.tec-safe.com  

For further info, please email: technical@tec-safe.com

References

OpenAI GPTChat (Sept 2024) accessed 10 September 2024. 

  1. Legionella and dental waterline management. CQC. 2023. https://www.cqc.org.uk/guidance-providers/dentists/dental-mythbuster-5-legionella-dental-waterline-management 
  1. Health Technical Memorandum 04-01: Safe water in healthcare premises. NHS England. 2016. https://www.england.nhs.uk/publication/safe-water-in-healthcare-premises-htm-04-01/
  1. Health Technical Memorandum 01-05: decontamination in primary care dental practices. NHS England. 2013. https://www.england.nhs.uk/publication/decontamination-in-primary-care-dental-practices-htm-01-05/ 
  1. Shajahan, F., et al. Dental unit waterlines disinfection using hypochlorous acid-based disinfectant. Journal of Conservative Dentistry. 2016. https://journals.lww.com/jcde/fulltext/2016/19040/dental_unit_waterlines_disinfection_using.10.aspx#
  2.  Yue, C., Yuya, H., Zhihuan, L. et al. Study on the disinfection effect of chlorine dioxide disinfectant (ClO2) on dental unit waterlines and it’s in vitro safety evaluation. BMC Oral Health 24, 648. https://doi.org/10.1186/s12903-024-04391-7
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