A perfect hurricane: Dental waterline safety

Avoid a catastrophe in the dental office by carefully ensuring water quality

The 2000 movie The Perfect Storm gave birth to more than an adventure story. It created a popular phrase now commonly used to describe a combination of events—which are not individually dangerous—but occurring together produce a disastrous outcome.1 Do you ever wonder if an oncoming perfect storm could be avoided? Ever wonder if just one voice, one courageous action could be the catalyst that halts the devastation a storm path leaves behind?

When I thought about using the phrase, perfect storm, to share the story of the Flint, Michigan, water crisis it honestly seemed too weak and too soft. It also seemed cruel to combine the words perfect and storm to describe the devastation this event caused. Living only 63 miles away from the epicenter of this event, I saw and felt the fear, sadness, shock, anger, and frustration that thousands of residents had to deal with when their water supply was found to be contaminated with lead. Although this water crisis didn’t affect me physically, it affected people and strangers that I cared deeply for. This wasn’t the result of a perfect storm; I believe it was more the result of a perfect hurricane.

Quick Background

In April 2014, city officials in Flint, in an effort to save money, had their water supply switched from the Detroit water supply to the Flint River system. The ultimate goal of this action was to buy time until a new waterline connecting Flint to the Lake Huron water supply, was completed. This was projected to take between two and three years to complete, making the Flint River water source a short-term solution.

Sadly, this action had devastating results.2 I believe that no one making those financial decisions set out to harm the public, but it happened. Officials neglected to properly treat the Flint River water which tragically leached lead from old water pipes right into residents’ drinking water supply.3 Lead is a known neurotoxin that affects both behavior and cognitive abilities. It has longer term effects, especially in children.4

As this perfect hurricane was brewing in the water pipes of Flint citizens, one pediatric doctor began to see the medical evidence of this storm. One lone voice, Dr. Mona Hanna-Attisha, began to lead the way out of this hurricane. After listening to a colleague of hers, who had worked for the Environmental Protection Agency with the District of Columbia, Dr. Hanna-Attisha began acting on her suspicions that something was not right with the Flint drinking water. Dr. Hanna-Attisha wisely collected research-based evidence that typically would have first been published in a medical journal.

Thankfully, she took bold action and instead went directly to the public via press conference. She was challenged at first but eventually, the evidence won out and action was finally taken to respond to the crisis. One courageous lone voice helped halt this hurricane!

Still not convinced that dental waterline safety is important? Two documented cases confirm that dental waterlines caused great harm and even death.

Local Water Supply

To date, Flint Michigan has many new systems set in place to help the residents affected by this crisis. It may take years though to stabilize and recover from the effects of this tragedy but the effort has begun.

For me personally, it brought to the surface how truly vulnerable our water supply is. Not just our residential water supply, but also our places of work. Responding to your water quality at home should be as simple as a phone call to your city’s water department or a google search of your city’s water testing results. If you have well water, a very simple test could be done through your city’s health department. You can also purchase water testing kits from online sources.

There are many viable options available to assure your residential drinking water is safe.

What about your dental operatory waterline safety, though? What if the water you drew from was suddenly deemed unsafe to use in your dental practice? Not just for a few short days, but possibly for months, even years. The Flint water crisis event awakened me to this vulnerability. It propelled me to ask more questions, to seek more information, and learn how I could become a stronger link in the chain of water quality and safety.

To date, I had been very fortunate to benefit from a co-worker’s efforts to keep our waterlines clean. I faithfully followed the protocol she set up, but truthfully, she had been doing all the heavy lifting with this issue. I had done very little in researching exactly what needed to be done to our waterlines, why it needed to be done, and how I could share the load.

So let’s begin at the beginning. The EPA (Environmental Protection Agency) and the CDC (Centers for Disease Control and Prevention) agree on standards that water quality is to be measured and held up to. These agencies consider ≤500 CFU’s, colony-forming units per milliliter (cfu/ml) of aerobic mesophilic heterotrophic bacteria to be safe in our waterlines. To date, the American Dental Association also agrees with this standard.5

Still not convinced that dental waterline safety is important though? Two documented cases confirm that dental waterlines caused great harm and even death.

In 2012, an 82-year-old woman’s death from Legionnaire’s Disease was traced to the dental office she had received care from.6 This tragic event brought to the forefront the need for dental waterline safety and management.

Between the year 2014 and 2016, it was confirmed, that due to unsafe dental waterlines, a pediatric clinic in Georgia infected 20 children with Mycobacterium abscessus odontogenic infections during pulpotomy procedures.7 Again, no one set out to harm these innocent children but the lack of waterline accountability led to 20 children undergoing post-treatment procedures that included three month cycles of strong antibiotics and some children lost additional teeth and parts of their jaws.

A dental water system

Moving forward, it is now highly recommended you use a closed water system for each dental unit in your office to help manage and prevent additional health tragedies. Contact your local dental equipment support team to make this happen. These systems are affordable, easy to maintain, easy to conduct testing, easy to shock the waterlines, and ultimately easier to inhibit biofilm formation.

Keep in mind these systems will require a good, clean water source though. If that source is from tap water, it is controlled by the municipality you reside in. Consider contacting your municipal water department for their regulations and monitoring procedures. Distilled water is also an option. Distilled water may contain fewer minerals than your tap water does. These minerals have the potential to build up in waterlines and could lead to electric handpiece malfunction. If you go this route and purchase gallon containers of distilled water, do not store them in direct sunlight. Spring or purified water is another source to consider and is also acceptable to use in a closed water system.

With a closed water system, you will need to choose another supporting piece of equipment to achieve water safety. One viable option is the Sterisil Straw.8 This system can be used with municipal tap water or distilled water. It is a silver based product and includes an initial shock treatment built into the system. You won’t need to empty your water bottles at night or purge the waterlines. You will need to replace this straw once a year. The other option is the DentaPure Cartridge.9 This system also uses municipal water. It is an iodine-based product but does not contain the protein that cause allergic reactions to iodine. It too provides safe water for one year with simple installation procedures.

As simple as this next piece of advice may sound, please don’t ignore it. Flush all water lines every morning. This is critical! Flush your air/water syringes, your handpieces and ultrasonic lines. Remember, Aristotle said, “Quality is not an act, it is a habit.”10

Once you establish waterline safety procedures in your dental office, take the time to educate your staff on these actions. Again, practice will make perfect if every team member is on board. The American Dental Association (ADA) also strongly recommends having the emerging water from the dental unit tested. This is ultimately the only way you will know if your waterline safety system is effective. Seven different agencies are listed below that provide water testing for dental waterlines. Please note that the American Dental Association does not have an evaluation program for these services. What is listed below is not an endorsement by the ADA. It is only a listing of available services.11

Agenics, LLC at agenics.net

Aquaknow at aquaknow.com

Loma Linda University School of Dentistry Sterilization and Waterline Monitoring at dentistry.llu.edu/research/faculty-research/projects/sterilization-and-waterline-monitoring

Micro Test Lab, Inc. at microtestlabsinc.com

ProEdge Dental Products at proedgedental.com

The Texas A&M University System Health Science Center Baylor College of Dentistry Comprehensive Dental Monitoring Services at dentistry.tamhsc.edu/research/cdms/brochure.pdf

University of North Carolina School of Dentistry Sterilization Monitoring Service at dentistry.unc.edu/dentalprofessionals/services

In closing, I highly encourage you to locate a continuing education class on waterline safety. Connect with your dental supply representative to begin collecting options for your waterline systems. Once you establish a waterline safety protocol, have the end water product tested.

Don’t let someone else do all the heavy lifting in waterline protection as I had done. Knowing that just 63 miles away from me a “perfect hurricane” hit and caused lifelong consequences will remain my catalyst in trying to prevent those storms from re-occurring. I’d rather be a part of a “perfect world” than a “perfect storm” even if that means I need to boldly step into the storm’s path.

JUDITH M. STEIN, RDH, is a 1981 graduate of Kellogg Community College in Battle Creek, Mich. Judy has enjoyed a variety of professional opportunities in her hygiene career, is committed to lifelong learning, and is now employed in private practice. The author is an active volunteer in several professional, community, and faith organizations. She can be reached at [email protected].