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The Water Quality Conundrum

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The Water Quality Conundrum

Water quality is a relative assessment. It can be hard to say with confidence, “my water is clean enough.” A lot of clinicians just assume their water quality meets some unknown standard of quality and have no inclination on how to verify their water quality is up to par. Water quality exists on a spectrum and depending on what kind of procedure is being performed, your water quality may not be up to snuff.

There are three primary grades of water quality when it comes dentistry: distilled, dental, and sterile. Each have their own specific qualities and specified uses. In this entry, we will quantify these grades of water and how different procedures will necessitate the use of different grades of water.

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Distilled/Distilled Quality Water

Oh, distilled quality water. Your subtle portrayal of cleanliness has led many a clinician a stray over the years. Distilled quality water is indeed cleaner than tap water. But technically speaking, what is distilled quality water? And, what is it suitable for use in a dental practice? Let’s find out!

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Distilled quality water is not “distilled water,” rather it refers to the relative purity in relation to distilled water. Distilled quality water, by Sterisil® standards, is water containing <10 parts per million (ppm) total dissolved solids (TDS).

Often, distilled and distilled quality water is used in instrument washers and autoclaves. Its low contaminate level ensures that no dried deposits are left on sterilized or sanitized equipment after cleaning.

By itself, distilled quality water is not suitable for use in the dental unit due to several factors we have covered ad nauseum on this blog. (see The Bacteria Problem). However, distilled quality water is an excellent base water for use with dental bottles in conjunction with tablets and straws. This is a powerful, proven formula for effective dental water production at the operatory.

Dental Water

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Dental water contains a residual chemical treatment, thus mitigating microbial content to <500 colony forming units (CFU). According to OSAP, dental water is suitable for all nonsurgical dental procedures that do not involve the “incision, excision, or reflection of tissue that exposes the normally sterile areas of the oral cavity.” For most routine dental procedures, this grade of water is suitable.

There are ample commercially available options for clinicians to ensure their water meets this standard. As a clinician, keep in mind the effective limitations of dental water: not sterile and not suitable for use in surgical procedures. A routine procedure can unexpectedly end up in surgical territory. Recognizing this and acting accordingly will protect the patients from an infection and the practice from a potential liability claim.

Sterile Water

Sterile water in the context of dentistry should conform to sterile water standards for irrigation or sterile saline solution from the United States Pharmacopeia (USP). You can find a very detailed description of sterile solutions here.

According to OSAP, sterile solutions should be used in the following instances:

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  • Biopsy

  • Periodontal surgery

  • Apical endodontic surgery

  • Implant surgery

  • Surgical extractions of teeth (e.g., removal of erupted or nonerupted tooth requiring elevation of mucoperiosteal flap, removal of bone or section of tooth, and suturing if needed.)

There are many other instances where discretion should be applied. Procedures such as nonsurgical tooth extractions, gingival procedures, and nonsurgical endodontic procedures are listed by OSAP as having the potential to warrant a sterile solution to lower the possibility of infection.

Sterile solutions should never be considered “sterile” if they are delivered through the dental unit. It is well documented that the dental unit is unsuitable for delivery of sterile solutions. It might be sterile going in, but it will most certainly develop some level of contamination before it leaves a handpiece. Always consult the manufacturers labeling for delivery of sterile solutions.

Expect the Unexpected

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Understanding the nature of the procedure to be performed, and the limitations of the water quality necessitated by that procedure, will help you as a clinician minimize the risk of water related infections. What’s acceptable for one procedure may not be acceptable for another. Always prepare accordingly and be ready should a procedure drift into a category that demands a higher standard of water purity.

 

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Dental Amalgam - EPA Rule by Confusion

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Dental Amalgam - EPA Rule by Confusion

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Dental Amalgam: A Brief History

Dentists are the number one nonindustrial disposer of mercury waste in the country. Yes, mercury waste. You remember that nasty little compound from your middle school science class right? It might as well have been in a vacuum tube behind bullet proof glass from the way my science teacher handled it. While the average person walking the street might not consider mercury in their daily routine, folks in the dental profession should.

Mercury has been used for more than 150 years in dental amalgam in conjunction with other metals such as tin, silver, and copper(1). Since it exists as a liquid at room temperature, it acts as a binding agent with the powdered alloy, holding the amalgam together and filling in the space left by the cavity.

According to the ADA, over 100 million Americans have at least 1 filling with mercury amalgam(2). This represents quite a lot of potential toxic waste floating around in society. Some of these fillings will inevitably be released in a clinical setting and most likely suctioned out of the mouth and into the wastewater system in the dental practice.

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EPA Final Ruling: 40 CFR Part 441

Fast forward to June 14, 2017, EPA releases their final ruling in June of 2017. Published and codified at 40 CFR Part 441,  the ruling effectively makes these preventative measures law. If the ruling applies to you, install an amalgam separator, follow the BMPs, and submit your one-time compliance report to your control authority. But elements of the BMP would become a hotly contested topic in the regulatory community.

The BMP reads as follows; “Dental unit water lines, chair-side traps, and vacuum lines that discharge amalgam process wastewater to a POTW must not be cleaned with oxidizing or acidic cleaners, including but not limited to bleach, chlorine, iodine and peroxide that have a pH lower than 6 or greater than 8.”(3) Straight forward right?

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The Devil in the Details

Not long after the final ruling had posted to the federal register, EPA published a correction and FAQ section to their website, directly addressing the BMP verbiage which references the use of oxidizing line cleaners.

EPA stated:

Does the final rule prohibit the use of oxidizing or acidic cleaners in dental unit water lines, chair-side traps, and vacuum lines? Yes. The clause that follows (“including but not limited to…”) is not an exhaustive list of oxidizing or acidic cleaners or qualities that make a cleaner oxidizing or acidic. For example, a cleaner that is oxidizing would be prohibited even if its pH is between 6 and 8.

On the very next line down, EPA also stated:

Does the prohibition on the use of oxidizing or acidic cleaners in dental unit water lines apply to cleaners used in the water supply lines that connect to items such as handpieces, ultrasonic scalers or air/water syringes? No. The purpose of the best management practice (BMP) specified in § 441.30(b)(2) is to prohibit the use of cleaners that solubilize mercury from dental amalgam in the wastewater lines in a dental facility. In developing the rule, EPA did not evaluate the use of cleaning products that may be used in dental equipment that is connected to water supply lines such as handpieces, ultrasonic scalers, or air/water syringes. While de minimus amounts of such products may eventually be indirectly discharged through a wastewater line in a dental facility, the prohibition in § 441.30(b)(2) was not intended to prohibit dental unit water line cleaning products when those products are used in water supply lines to ensure the safety of the water that dentists place in their patient's mouth.

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Confused Yet?

Clear as mud right? So why is this such a problem? It has been well established that oxidizing line cleaners contribute to the dissolution of mercury in the effluent waste water(4). When amalgam waste trapped in the separator comes in contact with an oxidizing line cleaner, the mercury is dissolved and released in to the effluent waste water. EPA felt the information compelling enough to address it with an actionable provision in the ruling but their attempt at clarification seems to have only made things more confusing. Do they not know what happens to handpiece water after it’s dispensed? Do they not know that dental water by definition implies water with a continuously present, residual chemical treatment, that is sprayed into the mouth, and then suctioned back out?  

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Do as we do, not as we say.

As stated in the federal ledger, “The purpose of this final rule is to set a uniform national standard that will greatly reduce the discharge of mercury-containing dental amalgam to municipal sewage treatment plants, known as POTWs, in the United States.” So why would they publish such a confusing clarification and further muddy the water for dentists? We have some ideas but that’s another discussion.

Here are the facts. Oxidizing line cleaners, regardless of pH, will contribute to the dissolution and discharge of mercury into the practice’s effluent waste water. If you are using an oxidizing line cleaner, and your suction lines drain to the same line that houses the amalgam separator, you are most likely discharging higher than acceptable amounts of mercury waste. Simply because EPA “did not evaluate the use of cleaning products that may be used in dental equipment that is connected to water supply lines such as handpieces, ultrasonic scalers, or air/water syringes,” that doesn’t mean mercury waste is not escaping the separator.

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It’s Your Call

So there you have it. In the words of the great British philosopher and statesman, “Refined policy ever has been the parent of confusion, and ever will be so as long as the world endures.” In the interest of full disclosure, we are a waterline treatment manufacturer whose products fully comply with all waterline BMPs and amalgam separators. Sterisil customers need not worry about these matters because silver is not a categorical oxidizer, regardless of pH, and will not contribute to the dissolution of mercury into the public works. For the rest of you out there, it’s your call. You can’t plead ignorance anymore. Are you smarter than the EPA?

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Strategies for Implementing Waterline Treatment for the First Time: Part 1

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Strategies for Implementing Waterline Treatment for the First Time: Part 1

Dental Waterline treatment can be downright scary the first time around. You want to make good use of your resources and get it right the first time. In part one of this two part installment of the Sterisil Waterline Blog, we give you the framework to build your own custom waterline treatment program. Be sure to subscribe at the bottom of the article to get the second half emailed to you. Enjoy!

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California: The Forefront of Dental Waterline Regulations

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California: The Forefront of Dental Waterline Regulations

Regulations and attitudes surrounding dental unit water quality are changing. The state of California has passed AB-1277 and SB-1491 which went into effect on the 1st of the new year. The bills are part of a concerted effort by state legislators to shore up deficiencies in infection control standards that may have contributed to the Orange County mycobacterium outbreak in 2016.

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Ultraviolet Dental Waterline Disinfectants - A Dental Healthcare Providers Guide

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Ultraviolet Dental Waterline Disinfectants - A Dental Healthcare Providers Guide

Ultraviolet (UV) disinfectants are another powerful tool in the quest to eliminate dental waterline pathogens. In this piece we try to give some perspective on how UV technology gained prominence in the medical field, what grade of UV light you should be looking at for your practice, and how dental health professionals can leverage them for better infection control in the dental water

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Municipal Tap Water

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Municipal Tap Water

The independent bottle reservoir was a significant evolution in dental unit technology. Their implementation provided dentists the ability to bypass the municipal supply and control dental water microbes with disinfectants. So why would you want to put tap water in that bottle? In this discussion, we'll give you some good reasons to think about using distilled water.  

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EPA Labels

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EPA Labels

This article covers the importance of EPA labels and what they mean to dental professionals. If you're wondering about whether or not you are following the right protocol this article will shed some light on the subject. 

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The Bacteria Problem

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The Bacteria Problem

Have you ever found yourself sitting in the dentist’s chair thinking “that’s a lot of hoses”?  Do you know how “clean” the water is coming out of the faucet and handpieces? If you find yourself asking these questions you’re not alone. In this entry we'll dig into detal waterlines and how concern you should be about their cleanliness. 

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Welcome!

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Welcome!

Your Source for Dental Water News

Do you sometimes feel there are massive amounts of rules and restrictions when it comes to maintaining your dental unit water lines? Maybe you're just looking for some general guidance in properly providing water to your dental facility.  

Here at Sterisil, we have noticed the difficulty of getting clear and concise information about the latest news and guidelines in the dental water treatment world.  As leaders in the dental water treatment industry, we'll be discussing the latest news, tips and general information on keeping your dental water in compliance.

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