Water Lines and Biofilms

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LEARNING OBJECTIVES
On completing this CPD article, the reader will:
1. Understand the risks posed by biofilms in dental unit waterlines (DUWLs)
2. Appreciate the realities of poorly maintained water lines in the dental practice
3. Recognise what constitutes infection control ‘best practice’ and why
4. Have a raised awareness of what complying with the law entails
5. Know what steps to take improve infection control processes, if needed.

Simon Davies explores the risky business of contaminated water lines in the dental practice and offers guidance on how to ensure your infection control processes are effective. There has long been debate about the reality of the risks posed by biofilms in DUWLs; some argue that, overall, the risk is negligible.1 Yet one California-based dentist may argue otherwise if he had the chance; sadly, he doesn’t, having reportedly died from exposure to legionella bacteria found in his DUWLs.2 That is one death too many in a world where it is entirely preventable with the right infection control measures in place. There have also been some close calls. There was the patient who suffered a brain abscess following dental treatment, who claimed that the illness was caused by contaminated water in the practice. She won an out-of-court settlement.3 And let’s not forget the two immunodeficient patients who became infected with Pseudomonas aeruginosa following a dental appointment, with the same strain identified in the practice’s DUWLs.3 Dental professionals, too, have been shown to be adversely affected by biofilms. One survey of dental practices in London and rural Northern Ireland revealed that the majority had DUWL bacteria over the ‘best practice’ count of 100 to 200 colony forming units per millilitre (cfu/ml) (as detailed in section 6.79 of HTM 01-05). Within those practices, 14% of dentists had asthma – a statistic significantly higher than the 5% average adult occupational asthma rate.1,4 The risks are real. What more do we need to know to take preventive action? ‘BEST PRACTICE’ As has already been mentioned, HTM 01-05: Decontamination in primary care dental practices offers ‘best practice’ guidance on DUWLs.5 Also important to consider are the Approved Code of Practice and guidance L8, Health and Safety .Executive (ALCOP L8),6 and HTM 04-01: The control of Legionella, hygiene, ‘safe’ hot water, cold water and drinking systems.7 Essentially, HTM 01-5 offers an overview of DUWL regulation in chapters 6 and 19, covering topics – to name just a few of note – including microbiological monitoring, disinfection processes, Legionella risk assessment and what to do in the case of an unexpected DUWL shut-down.5 It is further written in HTM 01-05: ‘The Health & Safety Commission’s Approved Code of Practice L8 gives practical advice on how to comply with UK health and safety law with respect to the control of Legionella bacteria. This Code is important in that it has a special legal status. If a healthcare organisation is prosecuted for a breach of health and safety law, and it is held that it did not follow the relevant provisions of the Code, that organisation would need to demonstrate that it had complied with the law in some other way, or a court would find it at fault.’5 Therefore, despite not being compulsory, meeting the requirements in ALCOP L8 is pretty much essential if you want to be sure that you are complying with the law.6 In overview, duty holders should:
1. Identify and assess sources of risk. This includes checking whether conditions will encourage bacteria to multiply
2. Where appropriate, prepare a written scheme for preventing or controlling the risk (covered by paragraphs 58 to 64 of ALCOP L8)
3. Implement, manage, and monitor precautions – for control measures to be effective, regular monitoring of the systems and control measures is essential (for further information, see paragraphs 65 to 69)
4. Keep records of the precautions taken (paragraphs 70 to 74 offer additional
guidance on this)
5. Appoint a competent person with sufficient authority and knowledge of the installation to help take the measures needed to comply with the law (expectations are detailed in paragraphs 48 to 51 inclusive).
6. Completing the triumvirate of regulatory documents is HTM 04-01: The control of Legionella, hygiene, ‘safe’ hot water, cold water and drinking systems. Its aim is to provide guidance for a holistic approach to controlling Legionella, and was, ‘[…] written to promote good practice for those responsible for the design, installation, commissioning, operation and maintenance of water services in healthcare premises.
7. The list of how this can be achieved is extensive, but includes:
• The need for robust governance and management of water systems
• An outline of key criteria and system arrangements to help stop microbial contaminants, microbial colonisation and bacteria proliferation
• How the correct selection of system components and correct use by occupants can help preserve the quality and hygiene of water supplies
• Identifying fundamental commissioning, testing and maintenance requirements for referral by designers, installers, commissioners, operators and management.
8. For comprehensive information on these and more, please see HTM 04-01 itself. TAKE ACTION NOW
It is important to realise that not all ‘waterline cleaners’ are ‘biofilm disinfectants’. If your ‘waterline cleaner’ doesn’t do the job effectively, your water may well be contaminated with a host of potentially dangerous contaminants, such as:
• Legionella spp, which is a major contributor to Legionnaire’s disease
• Moraxella spp, which may cause endocarditis (a potentially fatal infection of the inner lining of the heart)
• Mycobacterium spp, which can result in pulmonary disease and opportunistic
wound infections
• Pseudomonas aeruginosa, which can cause pneumonia in immunocompromised patients.
9. The good news is that there is a simple solution. For almost 10 years, CleanCert has been providing dental practices and laboratories with simple and effective infection control solutions. CleanCert+ biofilm cleaner, for example, is a revolutionary one-stage waterline cleaner that is independently proven to be efficacious, as well as safe and simple to use. Impartial testing shows that, after using CleanCert+, the bacterial loading will be eliminated and the TVC (total viable count) dip slide reading will be zero (0 cfu/ml). It is used exclusively by the largest global dental group (My Dentist/IDH) across their 700-practice estate, a true testimony to its effectiveness.
CONTACT
To achieve ‘best practice’, to the benefit of both your team and your patients,
please visit cleancert.co.uk, email sales@cleancert.co.uk or call 08443 511115, for further information on the full range of proven, innovative dental infection control and water purification products available from CleanCert. To provide feedback on this article, please contact cpdfeedback@cleancert.co.uk

Welcome to your Water Lines and Biofilms
Tick the boxes you consider correct.

Name Business Email GDC Number
ACCORDING TO REPORTS, ONE CALIFORNIA-BASED DENTIST DIED OF WHAT DISEASE,FOLLOWING EXPOSURE TO A BACTERIUM FOUND IN HIS DUWLS?
WHAT IS THE MAXIMUM COUNT OF COLONY FORMING UNITS PER MILLILITRE (CFU/ML) PERMITTED IN THE 'BEST PRACTICE' ADVICE OF SECTION 6.79 OF HTM 01/05 (2013)?
THE PROFESSIONAL GUIDELINES ON INFECTION CONTROL AND DUWLS COMPRISE WHAT DOCUMENT(S)?
DESPITE NOT BEING COMPULSORY, MEETING THE REQUIREMENTS IN ALCOP L8 SHOWS WHAT?
INDEPENDENT TESTING RESULTS PROVE THAT, AFTER USING CLEANCERT+, THE BACTERIAL LOADING WILL BE ELIMINATED AND THE TVC DIP SLIDE READING
WILL BE WHAT?