MAY 2018 CLINICAL EBOOK SERIES CURRENT TOPICS IN ......exposure to blood rarely occurs, and it hap-pens even less frequently with exposure of non-intact skin. HCV is not known to be

MAY 2018

Preventing Occupational Acquisition of Bloodborne Pathogens

2 C E C R E D I T S

Treating and Monitoring Dental WaterNancy Dewhirst, RDH, BS; and John A. Molinari, PhD

2 C E C R E D I T S

Charles John Palenik, MS, PhD, MBA

INFECTIOUS HAZARDS

WATER TESTING

SUPPORTED BY AN UNRESTRICTED GRANT FROM PROEDGE DENTAL WATER LABS • Published by AEGIS Publications, LLC © 2018

CLINICAL EBOOK SERIES POWERED BY

INFECTION CONTROL

CURRENT TOPICS IN

2 COMPENDIUM EBOOK SERIES May 2018

Take Nothing for Granted

of Continuing Education in Dentistry



AEGIS Publications, LLC104 Pheasant Run, Suite 105 Newtown, PA 18940

In many dental practices, as in most workplaces, it is easy to fall into a daily routine. We come to work, check our schedule, treat patients, clean up, and go home. Another day at the office, as they say. Although each patient is unique and may present distinctive challenges, we battle complacency every day.

Unfortunately, as healthcare workers, dental personnel can ill afford complacency, as patient and employee health and safety are constantly at stake. Numerous occupational hazards, both infectious and noninfectious, are ever-present in the dental office and pose serious risks. Fortunately, as highlighted in this issue of Compendium’s Clinical eBook Series, there are precautions dental professionals can take to minimize risk and maintain safe working conditions.

In our first continuing education (CE) article, the author identifies common hazards dental workers face on a daily ba-sis, including infectious agents such as bloodborne pathogens, patient blood, and other body fluids. The article discusses how exposures can, and do, occur in dental offices and presents strategies for preventing injury and infection.

The second CE article covers a topic that most of us likely take for granted every day—dental water safety. As the article notes, potentially pathogenic waterborne microorganisms can contaminate water in dental settings. Intended to help dental practices perform dental-unit water-line (DUWL) testing, this article discusses modes of microbial transmis-sion in dental environments and describes ways to moni-tor DUWL emissions, including use of in-office test kits and mail-in services.

In dentistry, with health hazards all around, patient and employee safety is paramount. My hope is that this eBook will serve as a valuable resource to practitioners seeking to maintain a safe—and enjoyable—workplace.

Sincerely,

Louis F. Rose, DDS, MD Editor-in-Chief [email protected]

MAY 2018 | www.compendiumlive.com

Chief Executive OfficerDaniel W. Perkins

PresidentAnthony A. Angelini

Chief Operating & Financial OfficerKaren A. Auiler

Corporate AssociateJeffrey E. Gordon

Subscription and CE informationHilary Noden877-423-4471, ext. [email protected]

PUBLISHERDental Learning Systems, LLC

SPECIAL PROJECTS MANAGERC. Justin Romano

SPECIAL PROJECTS EDITORCindy Spielvogel

SPECIAL PROJECTS COORDINATORJune Portnoy

BRAND DIRECTORMatthew T. Ingram

BRAND MANAGERAmelia Falcone

MANAGING EDITORBill Noone

CREATIVEClaire Novo

EBOOK DESIGNJennifer Barlow

COVER© AEGIS Publications, LLC

Copyright © 2018 by AEGIS Publications, LLC. All rights reserved under United States, International and Pan-American Copyright Conventions. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without prior written permission from the publisher.

PHOTOCOPY PERMISSIONS POLICY: This publication is registered with Copyright Clearance Cen ter (CCC), Inc., 222 Rosewood Drive, Danvers, MA 01923. Per mission is granted for photocopying of specified articles provided the base fee is paid directly to CCC.

Printed in the U.S.A.

mailto:lrose%40aegiscomm.com?subject=http://www.compendiumlive.commailto:hnoden%40aegiscomm.com?subject=

CONTINUING EDUCATION 1

3www.compendiumlive.com May 2018 COMPENDIUM EBOOK SERIES

INFECTIOUS HAZARDS

ABSTRACT: As healthcare workers, dental professionals face many occupational hazards, both noninfectious and infectious. Infectious agents to which dentists, hygienists, assis-tants, and others are exposed include bloodborne pathogens, such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Sharps-related injuries are also a common hazard for healthcare workers. The risk of blood-borne pathogen transmission is dependent on the prevalence of HBV, HCV, and HIV in the American population, the environmental survival of the bloodborne pathogens, and their transmissibility via percutaneous, mucous membrane, or intact skin exposure. This arti-cle discusses occupational hazards impacting healthcare personnel and precautions that can be taken to establish and maintain safe working conditions.

Preventing Occupational Acquisition of Bloodborne PathogensCharles John Palenik, MS, PhD, MBA

DISCLOSURE: The author reports no conflicts of interest associated with this work.

• Identify common noninfectious and infectious occupational hazards healthcare personnel face

LEARNING OBJECTIVES

• Describe how occupational exposure to bloodborne pathogens poses a threat to workers in the dental profession

• Discuss the prevalence and characteristics of hepatitis B, hepatitis C, and human immunodeficiency viruses

With a 5.6% increase in 2016, healthcare is the fastest grow-ing sector of the US economy, comprising 17.8% ($3.22 trillion in 2015) of the gross domestic product. The Centers for Disease Control and Prevention (CDC) estimated that 18 million people are working in the US healthcare industry and related occupations (eg, employees, employers, students, contrac-tors, public safety workers, and volunteers), and more than 900,000 are dental healthcare workers. Women represent nearly 80% of the current healthcare workforce.1-4

Healthcare workers (HCWs) face many non-infectious occupational hazards. Examples

include hazardous chemicals, latex allergies, lasers, radiation, stress, violence, strains, sprains, and heat/fire. Also, HCWs are ex-posed to infectious agents, including blood-borne pathogens, such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Occupational exposure to patient blood and other body flu-ids poses a serious public health concern.1,5

Healthcare Personnel and Occupational ExposuresMany HCWs are at risk for infectious occu-pational hazards. Exposure can involve: (1) percutaneous injuries with a contaminated sharp object (eg, needles, blades, pointed

http://www.compendiumlive.com


CONTINUING EDUCATION 1 INFECTIOUS HAZARDS

instruments, and broken glass); (2) direct contact (ie, contact without barrier protec-tion) and inhalation (via non-intact skin and mucous membranes); and (3) contaminated environment surfaces (eg, fomites) or instru-ments/equipment (ie, indirect contact). The number of nonfatal HCW occupational inju-ries and illnesses is the highest among any industry sector.1,3,5,6

The risk of bloodborne pathogen transmission is dependent on the prevalence of HBV, HCV, and HIV in the American population, the en-vironmental survival of the bloodborne patho-gens, and their transmissibility via percutaneous, mucous membrane, or intact skin exposure.1,5,6

Hepatitis B VirusThe seroprevalence of persons with active cases of HBV in the general population is approxi-mately 0.4%. HBV can survive and remain infec-tious outside source patients for 7 days or longer. HBV DNA can be detected on environmental surfaces in the absence of visible blood.1,5

HBV is primarily transmitted by percutane-ous or mucosal exposure. Efficiency of HBV transmission depends on viral load, route of transmission, and the immune status of the HCW affected. A generalized estimate of trans-mission after a percutaneous injury (used hol-low needle, not a solid instrument) is 33% (1 in 3) for HBV. Most HCW infections occurred before widespread vaccination began. In 1983, there were 10,000 occupationally acquired HCW cases. However, in 2002, there were few-er than 400. Hepatitis B vaccination is the most effective measure to prevent HBV infections. Immunization provides both pre- and post-exposure protection against HBV infection.1,5,6

Because of possible high viral loads and an ability to remain stable at ambient tempera-tures, HBV transmission also can occur after ex-posure to environmental surfaces or equipment that have been unsuccessfully disinfected.1,5

The need for post-exposure prophylax-is (PEP) after accidental percutaneous or

mucosal exposure to blood depends on sever-al factors. These include the hepatitis surface antigen status of the source patient (measure of infectivity), completion of the hepatitis B vaccination series, and vaccine response of the exposed HCW. Prophylaxis, if needed, should include prompt start of hepatitis B vaccination and injection of hepatitis B immune globulin.1,5

Hepatitis C VirusHCV is the most common chronic bloodborne infection in the United States, affecting an esti-mated 2.7 million to 3.2 million people. An esti-mated 30,500 acute hepatitis C cases occurred in 2014. The seroprevalence of persons capable of infecting others of HCV in the general popu-lation is approximately 1.3%.1,5,7

Environmental survival of bloodborne pathogens varies. HCV degrades at room temperatures even if within serum. Studies place HCV environmental survival between 16 hours and a maximum of 4 days. The potential for environmental survival and the possible presence of HCV-contaminated blood envi-ronmentally allows for the potential risk of transmission in healthcare settings.1,5,7

HCV transmission occurs primarily through exposure to infected blood. A generalized esti-mate after a percutaneous injury (used hollow needle, not a solid instrument) is 1.8% (1 in 55). Transmission from mucous membrane exposure to blood rarely occurs, and it hap-pens even less frequently with exposure of non-intact skin. HCV is not known to be trans-mitted through airborne or causal contact.1,5,7

No vaccine exists to prevent HCV infection. Protection centers on limiting exposure to infec-tious blood. Currently, there is no PEP for HCV.5

Human Immunodeficiency VirusThe primary means for acquiring HIV among adults is the exchange of body fluids. Perinatal transmission also is possible. HIV is not trans-mitted by airborne routes, household or work-place contact, exposure to contaminated


INFECTIOUS HAZARDSCONTINUING EDUCATION 1

environmental surface, or insect vectors. HIV is readily inactivated by most common disin-fectants, including diluted household bleach (1:10 to 1:100).1,5

A generalized estimate for HIV after a percu-taneous injury (used hollow needle, not a solid instrument) is 0.3% (1 in 333).1,5,8,9 The envi-ronmental half-life for HIV is 28 hours with a potential maximum of several days.1 HIV acqui-sition by mucous membrane routes is 0.09% (1 in 1111) and by contact with non-intact skin is probably less than 0.1% (1 in 1000); however, this has not been completely quantified.1,5

HCWs sustaining accidental parenteral ex-posures must immediately clean the site with soap and water and seek immediate medical care. Mucous membrane exposures require liquid rinses. Exposed HCWs need baseline and regular follow-up counseling for 6 months (eg, at 6 weeks, 3 months, and 6 months) to diagnose infection development.

Preventing occupational exposure is the most important strategy for reducing the risk for occupational acquisition of HIV in-fection. However, if possible, there should also be a PEP plan. This includes whether the exposed person should receive PEP (an-tiretroviral medication taken as soon as pos-sible after exposure to reduce the chance of HIV infection) and what type of PEP regi-men is needed. For most HIV exposures that warrant PEP, a 4-week, two-drug regimen is recommended, starting as soon as possible after exposure (within 72 hours). If there is an increased risk of transmission (based on the viral load of the source and the type of exposure), a three-drug regimen is recom-mended. Other specific recommendations may apply if there is a delay in exposure re-porting, the source is unknown, the exposed person is pregnant, there is resistance of the source virus to antiretroviral agents, or there is toxicity of PEP regimens.1 The US Public Health Service recommends post-exposure chemoprophylaxis with antiretroviral agents

for needlesticks from HIV-infected sources and mucous membrane and non-intact skin exposures to such sources.1,5,8

Sharps InjuriesCDC estimates that about 385,000 sharps-related injuries (penetrating stab or punc-ture wound) occur annually among HCWs in hospitals. It is estimated that about at least half of sharps injuries go unreported. Most sharps injuries involve nurses; however, labo-ratory staff, physicians, housekeepers, and other HCWs also can be injured.7,8

In addition to the use of sharps devices, in-juries are also closely associated with certain work practices that can pose an increased risk of bloodborne pathogen exposure. Common work practices include disposal-related activi-ties; activities after use and prior to disposal, such as item disassembly; and recapping a used needle (Table 1).7-9

Also, injuries are closely associated with cer-tain devices that can pose an increased risk of bloodborne pathogen exposure. These devices include disposable syringes, suture needles, and other types of sharps (Table 2).8,9

Considering the frequency of their exposure to blood and other body fluids, the number of HCWs in the United States infected with

wTABLE 1Common Work Practices During Which Sharps Injuries Occur

Work Practice Percentage of Sharps Injuries

During Use of Item 48%

After Use, Before Disposal 30%

Disposal-related 11%

Recapping Used Needle 3%

Other 8%

Source: https://www.cdc.gov/niosh/stopsticks/sharpsinjuries.html

http://www.compendiumlive.comhttps://www.cdc.gov/niosh/stopsticks/sharpsinjuries.html



HIV through occupational exposure is quite small.1,5,8,10 The greatest HIV risk follows a percutaneous injury involving a contaminat-ed sharp, especially a hollow needle that has been in the vein or artery of an HIV-positive source patient. Risk increases for patients with Stage 3 HIV infection (ie, acquired im-munodeficiency syndrome [AIDS]), as high viral loads are often involved this late in the disease process.1,3,9,10

In the United States, 58 confirmed cases and 150 possible cases of occupationally acquired HIV infection were reported to the CDC be-tween 1985 and 2013 (Table 3). Since 1999, however, only one confirmed case (a labora-tory technician who sustained a needle punc-ture while working with a live HIV culture in 2008) has been reported (Table 4). Of course, underreporting is a possibility because report-ing is voluntary.1,9,10

A confirmed case of occupationally acquired HIV infection requires documentation that seroconversion in the exposed HCW is tempo-rally related to a specific exposure to a known

HIV-positive source. A possible case of occu-pationally acquired HIV infection is defined as an infection in a HCW whose job duties might have exposed him or her, but who lacks a documented workplace exposure. The HIV status of a source patient may be unknown or the HCW seroconversion after exposure may not have been documented as tempo-rally related. Thus, occupational acquisition of HIV infection is possible without it being confirmed.3,10,11

Among the 58 confirmed cases, the routes of exposure resulting in infection were percuta-neous punctures or cuts (49 cases), mucocuta-neous exposures (5), both percutaneous and mucocutaneous exposures (2), and unknown (2). A total of 49 HCWs were exposed to HIV-infected blood, four to concentrated virus in a laboratory, one to visibly bloody fluids, and four to unspecified body fluids.3,10,11

Standard PrecautionsCDC recommends the use of standard precau-tions to prevent exposure of HCWs to poten-tially infectious body fluids when working with any patient, whether he or she is known to be infected with HIV or not. This means that HCWs should assume that all patient body fluids are potentially infectious.1,5,10 Properly implemented standard precautions include the use of safety devices and barriers such as gloves and protective eyewear to minimize exposure risk.1,5,10

To prevent puncture injuries, CDC rec-ommends a comprehensive prevention program consistent with requirements of the Occupational Safety and Health Administration’s Bloodborne Pathogens Standard.12 This includes use of medical de-vices engineered for sharps protection (eg, needleless, self-sheathing systems). Used de-vices such as syringes or other sharp instru-ments should be disposed of in sharps con-tainers without attempting to recap needles. While many factors come into play, safer work

wTABLE 2Devices Involved in Sharps Injuries

Device Percentage of Sharps Injuries

Disposable Syringe 31%

Suture Needle 24%

Winged-Steel Needle 5%

Reusable Scallop 4%

Disposable Scallop 4%

Other Needle 4%

Syringe, Prefilled Cartridge 3%

Intravenous Catheter 3%

Other Sharps Item 22%

Source: https://www.cdc.gov/niosh/stopsticks/sharpsinjuries.html

https://www.cdc.gov/niosh/stopsticks/sharpsinjuries.html



practices help reduce the chances of occupa-tional HIV exposure and result in lower num-bers of infections.

HIV Cases DroppingIn 2015, 39,513 people were diagnosed with HIV infection in the United States. The number of new HIV diagnoses fell 19% from 2005 to 2014. Because HIV testing has remained stable or slightly increased

in recent years, this decrease in diagnoses suggests a genuine decline in new infections. The decrease may be due to targeted HIV prevention efforts. However, progress has been uneven and diagnoses have increased among a few groups.10,13,14

At the end of 2014, the most recent year for which such data are available as of this writ-ing, an estimated 1,107,700 adults and adoles-cents were living with HIV with an estimated

wTABLE 3Occupational Risk of HIV Infection for Healthcare Worker, United States, 1985-2013

Number of Occupationally Acquired HIV Infections

Occupation Documented Possible

Nurse 24 (41%) 37 (25%)

Laboratory Worker, Clinical 16 (28%) 21 (14%)

Physician, Nonsurgical 6 (10%) 13 (9%)

Laboratory Worker, Nonclinical 4 (7%) 0

Housekeeping/Maintenance 2 (3%) 14 (9%)

Technician, Surgical 2 (3%) 2 (1%)

Embalmer/Morgue Worker 1 (2%) 2 (1%)

Health Aide/Attendant 1 (2%) 16 (11%)

Respiratory Therapist 1 (2%) 2 (1%)

Technician, Dialysis 1 (2%) 3 (2%)

Dental* 0 6 (4%)

Emergency Medical/Paramedic 0 13 (9%)

Physician, Surgical 0 6 (4%)

Technician/Therapist/Other 0 9 (6%)

Other Healthcare Occupations 0 6 (4%)

Total 58 150

Adapted from MMWR Morb Mortal Wkly Rep. 2015;63(53):1245-1246.*three dentists, one oral surgeon, and two dental assistants




166,000 (15%) remaining undiagnosed. Young people were the most likely to be unaware of their infection. Among people aged 13 to 24, an estimated 51% (31,300) of those living with HIV at the end of 2013 did not know it.3,10-12

Worldwide, the number of newly diagnosed cases of HIV dropped about 33% (3.4 mil-lion to 2.3 million) from 2001 to 2013. Also,

potent antiretroviral therapy has significantly increased longevity among HIV-infected pa-tients. As this patient population grows older, an increased need for surgical interventions, such as coronary revascularization, will likely rise. Concerns about HIV-positive patients who need surgery include morbidity and mortality, preoperative evaluation, and post-surgical management. It is estimated that 25% of these individuals will need surgical/anes-thesia treatment during their illness.10,13,14

ConclusionHealthcare workers, including dental person-nel, are constantly at risk for both noninfec-tious and infectious occupational hazards, and the risk of bloodborne pathogen transmission is quite prevalent. Occupational exposure to patient blood and other body fluids poses a serious health concern, and proper care must be emphasized to prevent occupational acqui-sition of bloodborne pathogens.

ABOUT THE AUTHORCharles John Palenik, MS, PhD, MBAPresident and CEO, GC Infection Prevention and Control Consultants, Indianapolis, Indiana. In 2011, Dr. Palenik re-tired after 35 years at Indiana University School of Dentistry, where he held a number of academic and administrative po-sitions, including Professor of Oral Microbiology, Director/Human Health & Safety, Director/Central Sterilization Services, and Chairman/Infection Control and Hazardous Materials Management Committees.

Queries to the author regarding this course may be submitted to [email protected].

REFERENCES1. Weber DJ, Rutala WA. Occupational health update: focus on preventing the acquisition of infections with

pre-exposure prophylaxis and postexposure prophy-

laxis. Infect Dis Clin North Am. 2016;30(3):729-757.

2. Drum K. Chart of the day: health care spend-ing as a percentage of GDP. Mother Jones website.

June 5, 2017. http://www.motherjones.com/kevin-

wTABLE 4Number of Confirmed Cases (N = 58) of Occupationally Acquired HIV Infection Among Healthcare Workers Reported to the CDC, United States, 1985-2013

Year No. of Confirmed Cases

1985 3

1986 5

1987 7

1988 6

1989 4

1990 6

1991 7

1992 8

1993 3

1994 1

1995 4

1996, 1997 0

1998 1

1999 2

2000-2007 0

2008 1

2009-2013 0

Adapted from MMWR Morb Mortal Wkly Rep. 2015; 63(53):1245-1246.

mailto:[email protected]

9www.compendiumlive.com


May 2018 COMPENDIUM EBOOK SERIES

drum/2017/06/chart-day-health-care-spending-

percentage-gdp/. Accessed August 1, 2017.

3. National Institute for Occupational Safety and Health. Healthcare workers. Centers for Disease

Control and Prevention website. Updated March 14,

2017. http://www.cdc.gov/niosh/topics/healthcare/.

Accessed August 1, 2017.

4. Solomon ES. The past and future evolution of the dental workforce team. J Dent Educ. 2012;76(8):

1028-1035.

5. Miller S. Occupational exposure to bloodborne pathogens. In: Grota P, ed. APIC Text of Infection

Control and Epidemiology. Washington, DC: Asso-

ciation for Professionals in Infection Control and

Epidemiology; 2014.

6. National Institute for Occupational Safety and Health. Bloodborne infectious diseases: HIV/AIDS,

hepatitis B, hepatitis C. Centers for Disease Con-

trol and Prevention website. Updated April 5, 2017.

https://www.cdc.gov/niosh/topics/bbp/default.html.

Accessed August 1, 2017.

7. Centers for Disease Control and Prevention. Hep-atitis C FAQs for health professionals. Centers for

Disease Control and Prevention website. Updated

January 27, 2017. https://www.cdc.gov/hepatitis/hcv/

hcvfaq.htm#section. Accessed August 1, 2017.

8. Centers for Disease Control and Prevention. Oc-cupational HIV transmission and prevention among

health care workers. Centers for Disease Control

and Prevention website. Updated November 7, 2016.

https://www.cdc.gov/hiv/workplace/healthcare-

workers.html. Accessed August 1, 2017.

9. National Institute for Occupational Safety and Health. Stop sticks campaign. Centers for Disease

Control and Prevention website. Updated June 24,

2011. https://www.cdc.gov/niosh/stopsticks/sharp-

sinjuries.html. Accessed August 1, 2017.

10. Joyce MP, Kuhar D, Brooks JT. Notes from the field: occupationally acquired HIV infection among health

care workers – Unites States, 1985-2013. MMWR Morb

Mortal Wkly Rep. 2015;63(53):1245-1246.

11. Centers for Disease Control and Prevention. HIV in the United States: at a glance. Centers for Disease

Control and Prevention website. Updated June 9,

2017. https://www.cdc.gov/hiv/statistics/overview/

ataglance.html. Accessed August 1, 2017.

12. OSHA Fact Sheet. OSHA’s Bloodborne Patho-gens Standard. Occupational Safety and Health

Administration. https://www.osha.gov/OshDoc/

data_BloodborneFacts/bbfact01.pdf. Accessed

August 1, 2017.

13. Wyzgowski P, Rosiek A, Grzela T, Leksowski K. Oc-cupational HIV risk for health care workers: risk factor

and the risk of infection in the course of professional

activities. Ther Clin Risk Manag. 2016;12:989-994.

14. Prout J, Agarwal B. Anaesthesia and critical care for patients with HIV infection. Continuing Education

in Anaesthesia, Critical Care & Pain. 2005;5(5):153-156.


2 Hours CE CreditCONTINUING EDUCATION 1 QUIZ


1. Women represent nearly what percent of the current healthcare workforce in the United States?

A. 20%B. 40%C. 60%D. 80%

2. Which of the following is a bloodborne pathogen?

A. hepatitis B virus (HBV)B. hepatitis C virus (HCV)C. human immunodeficiency virus (HIV)D. All of the above

3. The number of nonfatal healthcare worker occupational injuries and illnesses is:

A. the lowest among any industry sector.B. the same as most other industry sectors.C. the highest among any industry sector.D. None of the above

4. Efficiency of HBV transmission depends on viral load, route of transmission, and:

A. the overall health of the American population.B. the room temperature of where the exposure occurred.C. the immune status of the healthcare worker affected.D. how quickly the used needle is disposed of.

5. The most common chronic bloodborne infection in the United States is:

A. HBV.B. HCV.C. HIV.D. HCW.

6. With no vaccine available to prevent HCV infection, protection centers on:

A. limiting exposure to infectious blood.B. post-exposure prophylaxis (PEP).C. keeping disinfectants in the office.D. seeking immediate medical care.

7. The primary means for acquiring HIV among adults is:

A. the exchange of body fluids.B. perinatal transmission.C. failing to use personal protective equipment (PPE) in the workplace.D. All of the above

8. For most HIV exposures that warrant PEP, a 4-week, two-drug regimen is recommended, starting:

A. within 72 hours after exposure.B. 4 days after exposure.C. 4 weeks after exposure.D. after the infection has reached Stage 3.

9. Sharps injuries that can pose an increased risk of bloodborne pathogen exposure are associated with which of the following work practices?

A. disposal-related activitiesB. item disassemblyC. recapping a used needleD. All of the above

10. To prevent puncture injuries, the Centers for Disease Control and Prevention (CDC) recommends a comprehensive prevention program consistent with requirements of: A. the CDC “Healthcare Workers” web page. B. the NIOSH “Stop Sticks Campaign” web page. C. the OSHA Bloodborne Pathogens Standard. D. the Morbidity and Mortality Weekly Report.

TAKE THIS FREE CE QUIZ BY CLICKING HERE: COMPENDIUMLIVE.COM/GO/CURRENTTOPICSIC1 ENTER PROMO CODE: CTIC1

Course is valid from 5/1/18 to 5/31/21. Participants must attain a score of 70% on each quiz to receive credit. Partici-pants receiving a failing grade on any exam will be notified and permitted to take one re-examination. Participants will receive an annual report documenting their accumulated credits, and are urged to contact their own state registry boards for special CE requirements.

Approval does not imply acceptance by a state or provisional board of dentistry or AGD endorsement. The current term of approval extends from 1/1/2017 to 12/31/2022. Provider #: 209722.

AEGIS Publications, LLC, is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp.

CONTINUING EDUCATION 1 QUIZ 2 Hours CE Credit


http://COMPENDIUMLIVE.COM/GO/currenttopicsIC1http://www.ada.org/cerp


CONTINUING EDUCATION 2 WATER TESTING


The association between water-borne microorganisms and human disease caused by contamination of water sources has been docu-mented since the mid-1850s.1 Since then, a wide variety of both microscopic and macroscopic forms have been shown to survive and proliferate in both natural water and manmade environmental systems (Table 1).2 Although established public health water-treatment regulations (ie, filtration and chlo-rination) have been in effect for many years, waterborne infection and disease outbreaks continue to be reported from drinking water, recreational water, hospital water, and water from healthcare-related devices. Extensive documentation of these types of infections can be found in medical literature.3-8 Until

recently, outbreaks and severe infections from contaminated water in healthcare settings were primarily reported in hospitals.

To put this public health issue into perspec-tive for dentistry, it was not until 1963 that Blake first reported high concentrations of bacterial accumulation in coolant water for high-speed dental handpieces.9 Later inves-tigations established that microorganisms in dental water-delivery systems could form biofilms leading to proliferation of very high concentrations of bacteria. Subsequent stud-ies have reported on (a) the variety and nature of detectable microbial forms; (b) mechanisms of microbial colonization in dental-unit water lines (DUWLs) to form biofilms; (c) potential infection problems heavily colonized water can present for patients and dental healthcare

ABSTRACT: Multiple approaches are available for treating dental-unit water lines (DUWL). When used appropriately, these treatments can aid facilities in meeting regu-lated water standards. As dental professionals continue to become better acquainted and more comfortable with the different options, an important quality control measure is the periodic testing of DUWL. Testing is the most reliable way to discover problems with compliance and also provides documentation of dental-unit water quality. Test kits for in-office use and mail-in testing services provide means for dental facilities to assess the effectiveness of their treatment protocols. This article is designed to assist dental profes-sionals in choosing and correctly performing DUWL testing.


DISCLOSURE: The author reports no conflicts of interest associated with this work.

• Identify representative potentially pathogenic waterborne microorganisms and list modes of microbial transmission in dental environments

• Describe available methods for monitoring dental-unit water-line (DUWL) emissions and interpret DUWL testing results

• Suggest monitoring protocol that meets current standards and is appropriate for a given facility

LEARNING OBJECTIVES




providers; (d) possible approaches for reducing microbial burden and maintaining safe, pota-ble water for patient care; and (e) developing test systems to monitor effectiveness of water-treatment procedures.10-15

Most microorganisms detected in dental water systems originate from the public water supply and do not usually present a high risk of disease for healthy dental patients. However, multiple bacteria normally isolated from colo-nized dental-unit water have the potential to cause infection and illness in patients with immune-compromising conditions. The infec-tion control challenge posed by contaminated DUWLs shifted in recent years from the cate-gory of “potential” to “documented” infection. Since 2012, one death due to Legionella pneu-mophila16 and two outbreaks of Mycobacterium abscessus infections have been reported among pediatric dental patients after treatment with dental water that was heavily colonized with bacteria.16-18 Fortunately, continued progress to address this emerging problem has led to development of multiple approaches aimed at reducing dental-water colonization from envi-ronmental and human sources.

As more dental professionals adopt and routinely use available water-treatment

technologies, many are asking questions concerning testing and looking for assur-ance that products and procedures are being used correctly. Among the questions:

• What water-monitoring systems are available to test microbial loads in dental water?

• Do these monitoring systems provide accurate and useful information concerning effectiveness of practice treatment procedures?

• What are appropriate aseptic procedures when collecting water samples for testing?

These timely, appropriate questions serve as the major topics for the following discussion.

The Centers for Disease Control and Prevention, American Dental Association, and other public health agencies recom-mend that dental-treatment water meets the US Environmental Protection Agency (EPA) drinking-water standard of less than 500 colony-forming units per milliliter (CFU/mL) of non-coliform heterotrophic bacteria for routine (nonsurgical) proce-dures.19-21 Dental practices have been work-ing to meet this microbial threshold by using a combination of procedures, which involve the following:

wTABLE 1Representative Waterborne Disease Agents2

Bacterial Parasitic Viral

Escherichia coli Cryptosporidium Hepatitis A virus

Vibrio cholera Giardia Noroviruses

Salmonella typhi Schistosoma

Pseudomonas sp.

Shigella sp.

Legionella pneumophila

Non-tuberculous Mycobacterium sp.



• use of antimicrobial chemicals and technologies to control microbial colonization of DUWLs

• flushing lines in the beginning of the day and after each patient and emptying water lines overnight

• periodic application of DUWL “shock” treatments to augment routine treatment protocols

Basics of Water-Line TestingEvery dental facility is responsible for meet-ing the minimum DUWL standards to ensure patient and dental-worker safety. Testing water lines is the most reliable way to confirm and document that dental-water quality is accept-able. Many variables affect dental-water qual-ity and test results, and all testing methods currently used for dental-water testing are inherently limited. All heterotrophic plate count (HPC) methods reveal only a fraction of microorganisms in any water sample—no single method will recover all microorgan-isms.21 Dental-water testing is expected to detect elevated numbers of a spectrum of repre-sentative heterotrophic species for the purpose of detecting failure, or confirming success, of water-line treatment and management.

Water-line testing captures and assesses waterborne species of planktonic heterotro-phic bacteria at one point in time to estimate the amount of contamination within the lines. Biofilm communities change rapidly, requiring repeated testing to reliably monitor water qual-ity over time. Many factors can affect DUWL test results, including movement of tubing, water usage and flow, cycles of bacterial growth, and water-line antimicrobial treatment.

Although scientific researchers can identify and enumerate water microorganisms with great accuracy in laboratories, such processes are costly, time-consuming, and less practical for general DUWL testing. There is a need for affordable, efficient alternatives that provide a meaningful assessment of water safety.

Commercially available methods are designed to reduce cost and simplify the process by limit-ing parameters. Selection criteria for commer-cial water-testing methods should include the following considerations:

• selection for significant types of organisms (and omission of others)

• general efficacy (ability to grow and identify organisms)

• correcting for effects of residual antimicrobial agents

• time requirements• temperature requirements• technique difficulty• equipment needed• ease of interpretation• cost and practicality

The two basic options for water-line testing are in-office methods and mail-in water-test-ing services offered by commercial laborato-ries. In-office testing methods are designed to avoid the complexity, cost, and time required for laboratory testing methods, but they have been found to be less reliable than the standard laboratory water-testing methods used by vali-dated laboratories.21-23 Whatever the approach used, it should be designed to detect stressed organisms typically found in water lines that are being treated with commercial antibio-film products. These organisms are difficult to detect and grow in their starved inactive state but can proliferate in exposed susceptible hosts. Most water-line treatment products add a low-level chemical to the dental-treatment water to lower CFUs. Any residual antimicrobial chemical may affect test results by inhibiting bacterial growth during testing. In-office tests use water (with antimicrobial agents) directly from dental tubing without dilution or filtra-tion, whereas recommended laboratory test methods filter and serially dilute samples to reduce the effects of the antimicrobial products, allowing detection of these organisms.23


14


COMPENDIUM EBOOK SERIES May 2018

In-Office Water-Line TestingIn-office water-line tests include Aquasafe® (HPTC, hptcinc.com), available from dental supply companies; an in-office test is also avail-able as HPC Sampler from EMD Millipore (emdmillipore.com). The HPC sampler (Figure 1) is a dip paddle containing a 0.45-µm filter

and an absorbent pad with dehydrated agar medium within a plastic case. Dental-unit water is poured in the case, and then the paddle is dipped into the water. The paddle absorbs 1 mL of the liquid sample; the remaining liquid is discarded. The paddle is incubated at room temperature for 7 days. The manufacturer states that accurate readings are possible up to 300 CFU/mL. Over this amount the colo-nies grow together (confluent growth), with the results too numerous to count (TNTC).

There is evidence that the in-office method underestimates water contamination.21 Researchers identify two key reasons for poor growth of DUWL heterotrophic bacteria on HPC samplers: variation from room tempera-ture (22° to 28°C) and omission of neutraliza-tion of the test sample. Dental-water samples that contain residual antimicrobial agents should be neutralized to provide accurate results. However, HPC samplers may be consid-ered a useful gross screening method in primar-ily low-contamination situations, such as well-maintained and treated dental units.21,23,24

In-office testing places the burden of accu-racy on office personnel, requiring train-ing and dedication of time, space, and effort. Performing testing protocol using aseptic tech-nique and adhering to the optimal bacterial-growth schedule can pose a realistic challenge to dental teams. In addition, water-line testing records and results should be kept as part of the written safety program. With these consider-ations, regular in-office testing can provide a rough estimate of bacterial load and identify overgrowth events during ongoing water-line management procedures.

Mail-in Water-Line Testing ProcessesProfessional laboratories control many of the variables in the testing process, which improves the reliability of their results. Laboratories employ trained technicians who work under controlled conditions with regu-lated equipment. Standard Method 9215C

Fig 1..

Fig 2..

Fig 1. HPC sampler paddles. The paddle on the left is a passing test result. The paddle on the right is a failed test result. The membrane darkens when wet and can be slightly difficult to read. (Image provided by ProEdge Dental Water Labs, April 24, 2018) Fig 2. Water-line test vials with visible residual antimicrobial (blue) agent that will inhibit bacterial growth and alter test results unless neutralized by laboratory process-es. (Image provided by SAS, Loma Linda University, April 22, 2018)




WATER TESTING

R2A plating methodology is considered the gold standard for enumerating common heterotrophic bacteria in potable water. Standard Method 9215D adds filtration and dilution steps to neutralize water-line anti-microbials. Mail-in laboratory testing services that use these serial plating processes with low nutrient R2A agar, low incubation tempera-tures, and 5 to 7 days of incubation time yield a more accurate (higher) plate count than in-office methods.21,24,25 Sterile vials, a cold pack, and a box are provided by the labora-tory, and sample collection and shipping are managed by the customer. Samples must also be shipped overnight, and results are usually ready after a week of incubation (Figure 2).

Dental facilities should attempt to avoid the common errors that undermine water-line management efforts by using commercially available water-line antimicrobial products with recommended shocking procedures, care-fully following manufacturer’s instructions, and testing their water lines. Different lines in dental units have varied potential for biofilm accumulation and should be tested accord-ingly. Mail-in laboratories provide supplies and instructions along with guidance and consult-ing to assist offices in reaching recommended water-line safety standards. Evidence shows that after frequent (quarterly) testing proto-col is established, results improve to more than a 90% pass rate (ProEdge, unpublished data).

Why and When Should Dental Water Lines Be Tested?The recommendation to test DUWLs is targeted towards verifying the effective-ness of existing water-line management programs and confirming continual water potability. Unfortunately, errors may occur when

dental workers have undetected problems in their efforts to control water-line biofilms, thereby leading to failure of manage-ment procedures. Researchers previously reported audits of DUWLs showing that up to 50% of treated lines failed to meet pota-ble standards. These researchers suggested monthly testing protocol.23

To provide more information about dental offices that currently test their water lines, two dental-water testing laboratories, Sterilization Assurance Service (SAS) at Loma Linda University and ProEdge Dental Water Labs, were consulted. ProEdge Dental Water Labs provided anonymous data from 22,196 consec-utive test results, whereas both Loma Linda University and ProEdge Dental Water Labs provided generalized assessments based on 10 years of water testing. These water-line testing results were evaluated, comparing pass and fail rates based on the following: (1) various types of devices or lines, (2) water-line antimicrobial product used (or named by the dental office), and (3) number of tests performed (ProEdge, unpublished data).

Pass Rate by DeviceOne analysis compared test results from samples taken at different devices or lines. The results showed that 76.25% of air/water syringe hoses passed and 75.84% of the

wTABLE 2Pass Rate by Device

Pass Rate by Device This Data Set

Device Pass Fail Pass Rate (N = 1933)

Air/water syringe

976 304 76.25%

Handpiece 339 108 75.84%

Scaler 125 81 60.68%

Total 1440 493 74.50%




WATER TESTING

handpiece hoses passed, but only 60.68% of scaler hoses passed. Average pass rate for all types of lines was 74.5% (Table 2).

Although every DUWL should be tested, test-ing every port may be costly and time intensive. Instead, strategies for selecting representative ports or determining sequences for rotational testing protocol have been suggested, especially after repeated testing shows acceptable water quality (ProEdge, unpublished data; M. Rust, personal communication, January 2018). If a rotational testing protocol is considered, it may be advisable to test infrequently used lines as well as frequently used lines. Pooled samples from all water-bearing lines of each unit may also be tested. If contamination is detected, lines should be re-treated and retested, possi-bly including individual line samples (S. Mills, personal communication, April 2018).

Pass Rate by Product TypeIn addition to the testing for different types of water lines, various treatment protocols were compared. Table 3 represents field data accumulated from hundreds of dental facili-ties. The data reflect the potential misuse of

the individual products. Failed water tests are typically corrected after identifying mistakes such as not following manufacturer instruc-tions and not shocking on a regular basis.

The data show that periodic shocking combined with daily antimicrobial treatment yielded the highest pass rate (88%) and appears to be the most reliable long-term protocol. The average pass rate for all water that was treated with one of the above commercially available DUWL treatment products was found to be 70%. Shocking alone, without continuous water-line treatment, resulted in a 60% pass rate; using a daily treatment product without shocking yielded a 58% pass rate.

Although there are numerous options for water-line daily use cleaners, there are only two main options for shocking treatments: bleach (diluted 1:13 for a maximum 10-minute contact time) and commercially available shock products designed specifically for shocking of DUWL (left in lines overnight according to manufacturer’s directions). Scientific literature supports use of both options; however, bleach is more likely to damage dental-unit materi-als over time (M. Rust, personal communi-

cation, January 2018; S. Mills, personal communication, April 2018). Using bleach in DUWL is off-label use of the product and is inconsistent with its EPA registration (S. Mills, personal communica-tion, April 2018).

Pass Rate by Number of TestsAn important point made by both laboratories during interviews was that water-line samples from their customers often reveal high levels of contamina-tion initially but that those levels improve after repeated

wTABLE 3Pass and Fail Rates Summary by Treatment Type

R2A Pass and Failure Rate by Product Type (N = 22,196)

Product Type Pass Rate Failure Rate

Tablet with separate shock 88% 12%

Tablets 77% 23%

Straws/cartridges 72% 28%

Shock treatments only 60% 40%

Central systems 58% 42%

Daily liquids without shocking 58% 42%

Average (all methods) 69% 31%




WATER TESTING

testing. In one analysis of 3742 samples (Table 4, Figure 3), only 57% of the water samples passed (met the potable drinking water stan-dard of 500 CFU/mL) on the first test, but results improved after repeated testing. After five repeat tests, 85% of the samples met pota-ble standards.

Water-line testing must be continued over time because resistant biofilm species may rebound after several years of constant use of some DUWL antimicrobial products. Both laboratories offer consultation services, which they partially credit with improved water qual-ity and test results. Improved water test results are considered confirmation that the prod-uct, equipment maintenance, protocol, tech-nique, and compliance are successful. Keeping records of water-line test results as a record of compliance with safety standards can provide a facility with ongoing documentation of their efforts in this area (W. Zhang, personal communication, April 2018; M. Rust, personal communication, January 2018).

Understanding possible reasons for poor test results can aid in revising and improving a facility’s DUWL treatment protocols. Both testing services identified key reasons for poor test results. Before beginning water-line test-ing, safety managers can assist in avoiding typical errors by addressing and correcting

common problems. Management factors that are necessary for controlling water-line contamination and ensuring good test results include the following:

DUWL product manufacturer’s directions for

wTABLE 4Pass Rate by Number of Tests

Test No. Pass Fail R2A Pass Rate R2A Fail Rate Total

1st test 1146 559 57% 43% 1705

2nd test 735 200 72% 28% 935

3rd test 446 63 81% 19% 509

4th test 312 62 77% 23% 374

5th test 202 17 85% 15% 219

Total 2841 901 70% 30% 3742

wFIGURE 3Pass Rate by Number of Tests

1 2 3 4 5

57%

72%

81%77%

85%




WATER TESTING

use must be followed. Examples are regular shock treatments, correct dilution of prod-uct, correct sequencing or frequency of water treatment, and emptying water bottles or drying lines as recommended. All DUWLs should be shocked periodically with a strong chemical to remove biofilm. Water-line products retard (but do not prevent) biofilm growth. Biofilm builds up slowly and must be removed. Shock treatments are recommended weekly if a continuous antimicrobial product is not used; however, less- frequent shock procedures may be necessary when continuous antimicrobials are in place. Water-line testing can determine the optimal time interval for shocking as well as the need for shocking, even when manufacturers’ directions exclude shocking instructions (W. Zhang, personal communication, April 2018; M. Rust, personal communication, January 2018; S. Mills, personal communication, April 2018).

Source water should be clean. Distilled water, in-office distillers, and reverse-osmosis units may become contaminated over time. Filtered or processed water should be tested because filters may become contaminated. Municipal tap water may contain organisms that proliferate in DUWLs, and “hard” water with high total dissolved solids (TDS) can neutralize water-line treatment products. These contaminants in source water can exhaust active ingredients of antimicrobial products before water-line microbes are neutralized. It should be noted that TDS filters do not filter out microorganisms.

DUWLs should be flushed at the beginning and end of the day and between patients. Flushing is recommended to remove contaminated fluids after periods of stagna- tion and after possible retraction of patient- derived contaminants.

Shocking should not be confused with flush-ing processes. Shocking is the process of treating DUWLs with strong chemicals that

detach biofilm from the internal surfaces of water lines. Flushing is running treatment water through open ports of DUWLs, which removes fluids but will not reliably remove attached biofilms.

DUWLs should be tested consistently to confirm maintenance-protocol effectiveness and determine proper shock frequency.

SummaryMultiple approaches are available for treat-ing dental water. When used appropriately, these treatments can aid facilities in meeting regulated water standards. As dental profes-sionals continue to become better acquainted and more comfortable with the different options, an important quality control measure is the periodic testing of DUWLs. Testing is the most reliable way to discover problems with compliance and also provides docu-mentation of dental-water quality. Test kits for in-office use and mail-in testing services already provide means for dental facilities to assess the effectiveness of their treatment protocols. These products and services may become more user-friendly as new equip-ment management options and test meth-ods emerge. Nevertheless, dental profession-als should understand how to choose and correctly perform DUWL testing.

ABOUT THE AUTHORSNancy Dewhirst, RDH, BSDental Educator/Consultant/Writer, Professor, West Coast University, Anaheim, California

John A. Molinari, PhDProfessor Emeritus, University of Detroit Mercy, School of Dentistry, Detroit, Michigan; Director of Infection Control, Dental Advisor, Ann Arbor, Michigan

Queries to the authors regarding this course may be submitted to [email protected].

REFERENCES1. Snow J. On the mode of communication of cholera. In: Clendening L, ed. The Sourcebook of

mailto:[email protected]




WATER TESTING

Medical History. New York, NY: Paul B. Hoeber, Inc.; 1942:468-472.2. Molinari J. The ongoing challenge of waterborne infections. Inside Dent. 2017;13(8):52-58.3. Craun GF, Brunkard JM, Yoder JS, et al. Causes of outbreaks associated with drinking water in the United States from 1971 to 2006. Clin Microbiol Rev. 2010;23(3):507-528.4. Hlavsa MC, Roberts VA, Kahler AM, et al. Outbreaks of illness associated with recreational water—United States, 2011-2012. MMWR Morb Mortal Wkly Rep. 2015;64(24):668-672.5. Rutala WA, Weber DJ. Water as a reservoir of noso-comial pathogens. Infect Control Hosp Epidemiol. 1997;18(9):609-616.6. Decker BK, Palmore TN. The role of water in healthcare-associated infections. Curr Opin Infect Dis. 2013;26(4):345-351.7. Kanamori H, Weber DJ, Rutala WA. Healthcare outbreaks associated with a water reservoir and infection prevention strategies. Clin Infect Dis. 2016;62(11):1423-1435.8. McClung RP, Roth DM, Vigar M, et al. Waterborne disease outbreaks associated with environmen-tal and undetermined exposures to water—United States, 2013-2014. MMWR Morb Mortal Wkly Rep. 2017;66(44):1222-1225.9. Blake GC. The incidence and control of bacterial infection of dental units and ultrasonic scalers. Brit Med J. 1963;115:413-416.10. Martin MV. The significance of the bacterial con-tamination of dental unit water systems. Brit Dent J. 1987;163(5):152-154.11. Williams JF, Johnston AM, Johnson B, et al. Microbial contamination of dental unit water lines: prevalence, intensity, and microbial characteristics. J Am Dent Assoc. 1993;124(10):59-65.12. Karpay RI, Plamondon TJ, Mills SE, et al. Comparison of methods to enumerate bacteria in dental unit wa-ter lines. Curr Microbiol. 1999;38(2):132-134.13. Mills SE. The dental unit water line controversy: defusing the myths, defining the solutions. J Am Dent Assoc. 2000;131(10):1427-1441.14. Mills SE. Dental unit water and air quality

challenges. In: Molinari JA, Harte JA, eds. Cottone’s Practical Infection Control in Dentistry. 3rd ed. Philadelphia, PA: Wolters Kluwer; 2010:63-75. 15. Gruninger SE. Disease transmission through den-tal unit water: an update. ADA Professional Product Rev. 2014;9(2):8.16. Ricci ML, Fontana S, Pinci F, et al. Pneumonia associated with a dental unit water line. Lancet. 2012;379(9816):684.17. Peralta G, Tobin-D’Angelo M, Parham A, et al. Notes from the field: mycobacterium abscessus infections among patients of a pediatric dentistry practice – Georgia, 2015. MMWR Morb Mortal Wkly Rep. 2016;65(13):355-356.18. American Dental Association. Nontuberculous mycobacterial infection linked to pulpotomy pro-cedures and possible dental water line contamina-tion reported in California and Georgia. https://www.ada.org/en/science-research/science-in-the-news/nontuberculosis-mycobacterial-infection-linked-to-pulpotomy-procedures. Published September 21, 2016. Accessed May 15, 2018.19. Kohn WG, Collins AS, Cleveland JL, et al. Guidelines for infection control in dental health-care settings—2003. MMWR Recomm Rep. 2003;52(RR-17):1-61.20. Kohn WG, Harte JA, Malvitz DM, et al. Guidelines for infection control in dental health care set-tings—2003. J Am Dental Assoc. 2004;135(1):33-47.21. Porteous N, Sun Y, Schoolfield J. Evaluation of 3 dental unit water line contamination testing methods. Gen Dent. 2015;63(1):41-47.22. Cohen ME, Harte JA, Stone ME, et al. Statistical modeling of dental unit water bacterial test kit per-formance. J Clin Dent. 2007;18(2):39-44.23. Lal S, Singhrao SK, Brickness M, et al. Monitoring dental-unit-water-line output water by current in-office test kits. Curr Microbiol. 2014;69(2):135-142.24. Momeni SS, Tomline N, Ruby JD, Dasanayake AP. Evaluation of in-office dental unit water line testing. Gen Dent. 2012;60(3):e142-e147.25. Reasoner DJ. Heterotrophic plate count meth-odology in the United States. Int J Food Microbiol. 2004;92(3):307-315.

http://www.compendiumlive.comhttps://www.ada.org/en/science-research/science-in-the-news/nontuberculosis-mycobacterial-infection-linked-to-pulpotomy-procedureshttps://www.ada.org/en/science-research/science-in-the-news/nontuberculosis-mycobacterial-infection-linked-to-pulpotomy-procedureshttps://www.ada.org/en/science-research/science-in-the-news/nontuberculosis-mycobacterial-infection-linked-to-pulpotomy-procedureshttps://www.ada.org/en/science-research/science-in-the-news/nontuberculosis-mycobacterial-infection-linked-to-pulpotomy-procedures


20

ENAMEL REMINERALIZATIONCONTINUING EDUCATION 2 QUIZ 2 Hours CE Credit


1. Established public health water-treatment regulations include: A. intense laser purification. B. filtration and chlorination. C. controlled viral decontamination. D. desalinization.

2. For dentistry, it was not until 1963 that Blake first reported high concentrations of bacterial accumulation in: A. dental steam sterilization devices. B. the single-use bags sterile instruments are

stored in. C. coolant water for high-speed dental

handpieces. D. impression materials after taking an impression.

3. The majority of microorganisms detected in dental water systems originate from the: A. high-speed handpiece. B. low-speed handpiece. C. public water supply. D. low-speed suction unit.

4. Since 2012, how many outbreaks of Mycobacterium abscessus infections have been reported in pediatric dental patients after treatment with dental water that was heavily colonized with bacteria? A. none B. two C. 20 D. 200

5. The US Environmental Protection Agency drinking- water standard is less than how many colony-forming units per milliliter (CFU/mL) of non-coliform heterotrophic bacteria for routine (nonsurgical) procedures? A. 50 B. 500 C. 5,000 D. 50,000

6. Biofilm communities change rapidly, requiring: A. regular use of bleach in the water lines. B. repeated testing to reliably monitor water

quality over time. C. ionization treatment of the water at the source. D. ionization treatment of the water at the delivery

point.

7. Commercially available methods are designed to reduce cost and simplify the process by: A. increasing the number of CFUs allowed. B. only looking for fungal growth. C. reducing the frequency of required testing. D. limiting parameters.

8. Most water-line treatment products do what to the dental-treatment water to lower CFUs? A. add a low-level chemical B. add a broad-spectrum antibiotic C. add an antifungal agent D. boil the water before use

9. For mail-in water-line testing, how much incubation time yields a more accurate (higher) plate count than in-office methods? A. 1 hour B. 1 day C. 5 to 7 days D. 2 weeks

10. Evidence shows that after frequent (quarterly) testing protocol is established, results improve to more than what percentage pass rate? A. 30% B. 50% C. 70% D. 90%

TAKE THIS FREE CE QUIZ BY CLICKING HERE: COMPENDIUMLIVE.COM/GO/CURRENTTOPICSIC2 ENTER PROMO CODE: CTIC2

Course is valid from 5/1/18 to 5/31/21. Participants must attain a score of 70% on each quiz to receive credit. Partici-pants receiving a failing grade on any exam will be notified and permitted to take one re-examination. Participants will receive an annual report documenting their accumulated credits, and are urged to contact their own state registry boards for special CE requirements.

Approval does not imply acceptance by a state or provisional board of dentistry or AGD endorsement. The current term of approval extends from 1/1/2017 to 12/31/2022. Provider #: 209722.

AEGIS Publications, LLC, is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp.

COMPENDIUM EBOOK SERIES May 2018

http://COMPENDIUMLIVE.COM/GO/currenttopicsIC2http://www.ada.org/cerp

Safe water assurance starts atwww.proedgedental.com/test-kits

This is a testWE CAN HELP YOU PASS.Get your water tested with the most experienced dental water lab in the world. • Free expert consultations• Free FedEx return shipping• Protect your patients and your practice

ProEdge Dental Water Labs | 888-THE-EDGE (843-3343) | 7042 South Revere Parkway Ste 400, Centennial, CO
http://www.proedgedental.com/test-kits

Documents

MAY 2018 CLINICAL EBOOK SERIES CURRENT TOPICS IN ......exposure to blood rarely occurs, and it hap-pens even less frequently with exposure of non-intact skin. HCV is not known to be