Journal of Dentistry
Volume 35, Issue 9 , Pages 712-720 , September 2007

Do contaminated dental unit waterlines pose a risk of infection?

  • Caroline L. Pankhurst

      Affiliations

    • Department of Oral Medicine, King's College London Dental Institute, Bessemer Road, London SE5 9RW, United Kingdom
    • Corresponding Author InformationCorresponding author at: Department of Oral Medicine, King's College London Dental Institute, Bessemer Road, London SE5 9RW, United Kingdom. Tel.: +44 20 7848 1637.
  • ,
  • Wilson A. Coulter

      Affiliations

    • Oral Research Centre, School of Dentistry, Queens University Belfast, Grosvenor Road, Belfast BT12 6BP, Northern Ireland, United Kingdom
    • Tel.: +44 2890632539; fax: +44 2890438861.

Received 27 April 2007 ,Revised 1 June 2007 ,Accepted 5 June 2007.

References 

  1. Mackenzie W, Hoxie N, Proctor M, Gradus MS, Blair KA, Peterson DE. A massive outbreak in Milwaukee of cryptosporidium infection transmitted through the public water supply. New England Journal of Medicine. 1994;331:161–167
  2. Papapetropoulou M, Tsintzou A, Vantarakis A. Environmental mycobacteria in bottled table waters in Greece. Canadian Journal of Microbiology. 1997;43:499–502
  3. ADA Council on Scientific Affairs . Dental unit waterlines: approaching the year 2000. Journal of the American Dental Association. 1999;130:1653–1656
  4. Blake G. The incidence and control of infection in dental spray reservoirs. British Dental Journal. 1963;115:412–416
  5. Dodds MG, Grobe J, Stewart PS. Modeling biofilm antimicrobial resistance. Biotechnology and Bioengineering. 2000;68:456–465
  6. Lindsay D, von Holy A. Bacterial biofilms within the clinical setting: what healthcare professionals should know?. Journal of Hospital Infection. 2006;64:313–325
  7. Tall BD, Williams HN, George KS, Gray RT, Walch M. Bacterial succession within a biofilm in water supply lines of dental air–water syringes. Canadian Journal of Microbiology. 1995;41:647–654
  8. Barer MR, Harwood CB. Bacterial viability and culturability. Advances in Microbial Physiology. 1999;41:93–137
  9. Pederson ED, Stone ME, Ragain JC, Simecek JW. Waterline biofilm and the dental treatment facility: a review. General Dentistry. 2002;50:190–195
  10. Christensen R. More about waterlines. Journal of the American Dental Association. 2001;132:142
  11. Mills SE. The dental unit waterline controversy: defusing the myths, defining the solutions. Journal of the American Dental Association. 2000;131:1427–1441
  12. Batik O, Craun GF, Pipes WO. Routine coliform monitoring and waterborne disease outbreaks. Journal of Environmental Health. 1983;45:227–230
  13. Barbeau J, Nadeau C. Dental unit waterline microbiology: a cautionary tale. Canadian Dental Association. 1997;163:775–779
  14. Tuttlebee CM, O’Donnell MJ, Keane CT, Russell RJ, Sullivan DJ, Falkiner F, et al. Effective control of dental chair unit waterline biofilm and marked reduction of bacterial contamination of output water using two peroxide-based disinfectants. Journal of Hospital Infection. 2002;52:192–205
  15. Puttaiah R, Cederberg R. Assessment of endotoxin levels in dental effluent water. Journal of Dental Research. 1998;77:263
  16. Fulford MR, Walker JT, Martin MV, Marsh PD. Total viable count. ATP and endotoxin levels as potential markers of microbial contamination of dental unit water systems. British Dental Journal. 2004;196:157–159
  17. Putnins EE, Di Giovanni D, Bhullar AS. Dental unit waterline contamination and its possible implications during periodontal surgery. Journal of Periodontology. 2001;72:393–400
  18. CDC . Guidelines for infection control in dental health care settings. Morbidity and Mortality Weekly Report. 2003;52:1–66
  19. Schwartz DA. Does inhalation of endotoxin cause asthma?. Respiratory Critical Care Medicine. 2001;163:305–306
  20. Michel O, Kips J, Duchateau J, Vertongen F, Robert L, Collet H. Severity of asthma is related to endotoxin in house dust. American Journal of Respiratory Critical Care Medicine. 1996;154:1641–1646
  21. Mathew T, Casamassimo PS, Wilson S, Preisch J, Allen E, Hayes JR. Effect of dental treatment on the lung function of children with asthma. Journal of the American Dental Association. 1999;129:1120–1128
  22. Kauffman HF, van der Heide S. Exposure, sensitisation and mechanisms of fungus-induced asthma. Current Allergy and Asthma Reports. 2003;3:430–437
  23. Norback D, Bjornsson E, Janson C, Plagren U, Boman G. Current asthma and biochemical signs of inflammation in relation to building dampness in dwellings. International Journal of Tuberculosis and Lung Disease. 1999;3:368–376
  24. Tattersfield AE, Knox AJ, Britton JR, Hall IP. Asthma. Lancet. 2002;360:1313–1322
  25. Kogevinas M, et al. Occupational asthma in Europe and other industrialised areas: a population based study. Lancet. 1999;3532:1750–1754
  26. Pankhurst CL, Coulter W, 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. Primary Dental Care. 2005;12:53–59
  27. Scannapieco FA, Ho AW, DiTolla M, Chen C, Dentino AR. Exposure to the dental environment and presence of a respiratory illness in dental student populations. Journal of the Canadian Dental Association. 2004;70:170–174
  28. Mahmoudi M, Gershwin ME. Sick building syndrome. 111. Stachybotrys chartarum. Journal of Asthma. 2000;37:191–198
  29. Bjornsson E, Norback D, Janson C. Asthmatic symptoms and indoor levels of micro-organisms and house dust mites. Clinical Experimental Allergy. 1995;25:423–431
  30. Smedje G, Norback D, Edling C. Asthma among secondary schoolchildren in relation to the school environment. Clinical Experimental Allergy. 1997;27:1270–1278
  31. CDC . National nosocomial infection surveillance (NNIS) system report data (summary) October 1986–April 1996. American Journal of Infection Control. 1996;24:388
  32. Barbeau J, Tanguay R, Faucher E, Avezard C, Trudel L, Cote L, et al. Multiparametric analysis of waterline contamination in dental units. Applied Environmental Microbiology. 1996;62:3954–3959
  33. Rusin PA, Rose JB, Haas CN, Gerba CP. Risk assessment of opportunistic bacterial pathogens in drinking water. Reviews of Environmental Contamination and Toxicology. 1997;152:57–83
  34. Martin MV. The significance of the bacterial contamination of dental unit water systems. British Dental Journal. 1987;163:152–154
  35. Jensen ET, Giwercman B, Ojeniyi B, Bangsborg JM, Hansen A, Koch C, et al. Epidemiology of Pseudomonas aeruginosa in cystic fibrosis and the possible role of contamination by dental equipment. Journal of Hospital Infection. 1997;36:117–122
  36. Giesecke J. Choosing diseases for surveillance. Lancet. 1999;353:344
  37. Fiore AE, Butler JC, Emori TG, Gaynes RP. A survey of methods used to detect nosocomial legionellosis among participants in the National Nosocomial Infections Surveillance System. Infection Control Hospital Epidemiology. 1999;20:416–420
  38. Hoebe CJPA, Kool JL. Control of legionella in drinking water systems. Lancet. 2000;355:2093–2094
  39. Stone P. The Dentist's dirty secret. Californian Dental Association Journal. 2000;28:257–258
  40. Health and Safety Commission . Legionnaires’ disease. The control of legionella bacteria in water systems. Approved code of practice and guidance. 3rd ed.. UK: HMSO; 2000;
  41. Strauss WL, et al. Risk factors for domestic acquisition of Legionnaires disease. Archives of Internal Medicine. 1996;156:1685–1692
  42. Wadowsky RM, Wolford R, McNamara AM, Yee RB. Effect of temperature, pH and oxygen level on the multiplication of naturally occurring Legionella pneumophila in potable water. Applied Environmental Microbiology. 1985;48:1197–1205
  43. Ciesielski CA, Blaser MJ, Wang WL. Role of stagnation and obstruction of water flow in isolation of Legionella pneumophila from hospital plumbing. Applied and Environmental Microbiology. 1985;48:984–987
  44. Kwaik YA, Gao LY, Stone BJ, Venkataraman C, Harb OS. Invasion of protozoa by Legionella pneumophila and its role in bacterial ecology and pathogenesis. Applied Environmental Microbiology. 1998;64:3127–3133
  45. Pankhurst CL. Risk assessment of dental unit waterline contamination. Primary Dental Care. 2003;10:5–10
  46. Williams HN, Paszko-Kolva C, Shahamat M, Palmer C, Pettis C, Kelley J. Molecular techniques reveals high prevalence of Legionella in dental units. Journal of the American Dental Association. 1996;127:1188–1193
  47. Atlas RM, Williams JF, Huntingdon MK. Legionella contamination of dental-unit water. Applied Environmental Microbiology. 1995;61:1208–1213
  48. Pankhurst CL, Philpott-Howard JN, Hewitt JH, Casewell MW. The efficacy of chlorination and filtration in the control and eradication of Legionella from dental chair water systems. Journal of Hospital Infection. 1990;16:9–18
  49. Rangel-Frausto MS, Rhomberg P, Hollis RJ, Pfaller MA, Wenzel RP, Helms CM, et al. Persistence of Legionella pneumophila in a hospital water system: a 13-year survey. Infection Control Hospital Epidemiology. 1999;20:793–797
  50. Hambleton P, Broster MG, Denis PJ, Henstridge R, Fitzgeorge R, Conlan JW. Survival of virulent Legionella pneumophila in aerosols. Journal of Hygiene. 1983;90:451–460
  51. Fields BS, Benson RF, Besser RE. Legionella and Legionnaires’ disease: 25 years of investigation. Clinical Microbiology Reviews. 2002;15:506–526
  52. Benin AL, Benson RF, Besser RE. Trends in legionnaires disease, 1980–1998: declining mortality and new patterns of diagnosis. Clinical Infectious Diseases. 2002;35:1039–1046
  53. Marston BJ, Lipman H, Brelman RF. Surveillance for Legionnaires’ disease: risk factors for morbidity and mortality. Archives of Internal Medicine. 1994;154:2417–2422
  54. Al Shorman H, Nabaa LA, Coulter WA, Pankhurst CL, Lynch E. Management of dental unit waterlines. Dent Update. 2002;29:292–298
  55. Dutil S, Tessier S, Veillette M, Laflamme C, Meriaux A, Leduc A, et al. Detection of Legionella spp. by fluorescent in situ hybridization in dental unit waterlines. Journal of Applied Microbiology. 2006;100:955–963
  56. Zanetti F, Stampi S, De Luca G, Fatch-Moghdam P, Antonietta M, Sabattini B, et al. Water characteristics associated with the occurrence of Legionella pneumophila in dental units. European Journal of Oral Science. 2000;108:22–28
  57. Challacombe SJ, Fernandes LL. Detecting Legionella pneumophila in water systems: a comparison of various dental units. Journal of the American Dental Association. 1995;126:603–608
  58. Zacheous OM, Martikainen PJ. Occurrence of Legionella in hot water distribution systems of Finnish apartment buildings. Canadian Journal of Microbiology. 1994;40:993–999
  59. Pankhurst CL, Coulter WA, Philpott-Howard J, Harrison T, Warburton F, Platt S, et al. Prevalence of legionella waterline contamination and Legionella pneumophila antibodies in General Dental Practitioners in London and Rural Northern Ireland. British Dental Journal. 2003;195:591–594
  60. 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. Applied Environmental Microbiology. 2000;66:3363–3367
  61. Bartlett CL, Bibby LF. Epidemic legionellosis in England and Wales. Zentrablatt Bak Mikrobiol Hygiene. 1983;255:64–70
  62. Clark A. Bacterial colonisation of dental units and the nasal flora of dental personnel. Proceedings of the Royal Society of Medicine. 1974;67:29–30
  63. Reinthaler FF, Mascher F, Stunzer D. Serological examination for antibodies against legionella species in dental personnel. Journal of Dental Research. 1988;67:942–1042
  64. Fotos PG, Westfall HN, Synder IS, Miller RW, Mutchler BM. Prevalence of Legionella-specific IgG and IgM antibody in a dental clinic population. Journal of Dental Research. 1985;64:1382–1385
  65. Oppenheim BA, Sefton AM, Gill ON, Tyler JE, O’Mahony MC, Richards PJL, et al. Widespread Legionella pneumophila contamination of dental stations in a dental school without apparent human infection. Epidemiologyand Infection. 1987;99:159–166
  66. Chobot S, Malis J, Sebakova H, Pelikan M, Zatloukal O, Palicka P, et al. Endemic incidence of infection caused by Mycobacterium kansasii in the Karvina district in 1968–1995 (analysis of epidemiological data-review). Central European Journal of Public Health. 1997;5:164–173
  67. Montecalvo MA, Forester G, Tsang AY, du Moulin G, Wormser GP. Colonisation of potable water with Mycobacterium avium complex in homes of HIV infected patients. Lancet. 1994;343:1639
  68. Pankhurst CL, Coulter WA, Philpott-Howard J, Challacombe SJ, Harrison T, Warburton F, et al. Compliance with waterline management guidelines amongst dentists in London and Northern Ireland. Journal of Dental Research. 2002;81:446
  69. Porteous NB, Redding SW, Jorgensen JH. Isolation of non-tuberculosis mycobacteria in treated dental unit waterlines. Oral Surgery Oral Medicine Oral Pathology Oral Radiology & Endodontics. 2004;98:40–44
  70. Schulze-Robbecke R, Feldman C, Fischeder R. Dental units: an environmental study of sources of potentially pathogenic mycobacteria. Tuberculosis and Lung Disease. 1995;76:318–323
  71. Walker JT, Bradshaw DJ, Finney M, Fulford MR, Frandsen E, OStergaard E, et al. Microbiological evaluation of dental unit water systems in general dental practice in Europe. European Journal of Oral Sciences. 2004;112:412–418
  72. Wallace JR, Swenson JM, Sicox VA, Good RC, Tschen JA, Stone MS. Spectrum of disease due to rapidly growing mycobacterium. Reviews of Infectious Diseases. 1983;5:657–679
  73. Lohr DC, Goeken JA, Doty DB, Donta ST. Mycobacterium gordonae infection of a prosthetic aortic valve. Journal of the American Medical Association. 1978;239:1528–1530
  74. Chihota VN, Nyazema NZ, Mashinggaidze S, Mutandiro B. TB infection: an exploratory study of BCG protective properties and the possible role of environmental bacteria. Central African Journal of Medicine. 1998;44:145–148
  75. Rutala WA, Weber DJ. Uses of inorganic hypochlorite (bleach) in healthcare facilities. Clinical Microbiology Reviews. 1997;10:597–610
  76. Villanueva CM, Cantor KP, Cordier SJ, Jouni JK, King WD, Lynch CF, et al. Disinfection byproducts and bladder cancer: a pooled analysis. Epidemiology. 2004;15:357–367
  77. Savitz DA, Singer PC, Herring AH, Hartmann KE, Weinberg HS, Makarushka C. Exposure to drinking water disinfection by-products and pregnancy loss. American Journal of Epidemiology. 2006;164:1043–1051
  78. Karpay RI, Plamondon TJ, Mills SE, Dove SB. Combining periodic and continuous sodium hypochlorite treatment to control biofilms in dental unit water systems. Journal of American Dental Association. 1999;130:957–965
  79. Wirthlin MR, Marshall GW, Rowland RW. Formation and decontamination of biofilms in dental unit waterlines. Journal of Periodontology. 2003;74:1595–1599

PII: S0300-5712(07)00114-5

doi: 10.1016/j.jdent.2007.06.002

Journal of Dentistry
Volume 35, Issue 9 , Pages 712-720 , September 2007