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Research · Science Forschung · Wissenschaft Recherche · Science Water quality in dental treatment units Research and Science Research · Science Forschung · Wissenschaft Recherche · Science Publisher Editor-in-chief Editors Assistant Editors Herausgeber Chefredaktor Redaktoren Redaktions-Assistenten Editeur Rédacteur en chef Rédacteurs Rédacteurs assistants Schweizerische Zahnärzte- Adrian Lussi, Bern Urs Belser, Genève Brigitte Zimmerli, Bern Gesellschaft SSO Andreas Filippi, Basel Klaus Neuhaus, Bern Société Suisse Rudolf Gmür, Zürich d’Odonto-Stomatologie CH-3000 Bern 7 Adresse der Advisory board K.W. Grätz, Zürich T. Peltomäki, Zürich wissenschaftlichen Gutachtergremium Ch. Hämmerle, Zürich M. Perrier, Lausanne N. Hardt, Luzern Ch. Ramseier, Bern Redaktion Comité de lecture T. Imfeld, Zürich M. Richter, Genève Prof. Adrian Lussi T. Attin, Zürich K.H. Jäger, Basel H.F. Sailer, Zürich Klinik für Zahnerhaltung, P. Baehni, Genève J.-P. Joho, Genève G. Salvi, Bern Präventiv- und Kinder- J.-P. Bernard, Genève R. Jung, Zürich J. Samson, Genève zahnmedizin C.E. Besimo, Basel S. Kiliaridis, Genève U.P. Saxer, Zürich Freiburgstr. 7, 3010 Bern M.M. Bornstein, Bern I. Krejci, Genève J.-P. Schatz, Genève D. Bosshardt, Bern J.Th. Lambrecht, Basel S. Scherrer, Genève S. Bouillaguet, Genève N.P. Lang, Bern P.R. Schmidlin, Zürich U. Brägger, Bern T. Lombardi, Genève A. Sculean, Bern W. Buchalla, Zürich H.U. Luder, Zürich R. Seemann, Bern D. Buser, Bern H. Lüthy, Neuchâtel J. Türp, Basel M. Cattani, Genève C. Marinello, Basel H. van Waes, Zürich B. Ciucchi, Genève G. Menghini, Zürich P. Velvart, Zürich K. Dula, Bern R. Mericske-Stern, Bern T. von Arx, Bern D. Ettlin, Zürich J. Meyer, Basel T. Waltimo, Basel G. Eyrich, Zürich J.-M. Meyer, Chêne-Bougeries F. Weber, Zürich J. Fischer, Zürich T. Mitsiadis, Zürich R. Weiger, Basel L.M. Gallo, Zürich A. Mombelli, Genève A. Wichelhaus, Basel U. Gebauer, Bern W. Mörmann, Zürich A. Wiskott, Genève R. Glauser, Zürich F. Müller, Genève M. Zehnder, Zürich W. Gnoinski, Zürich S. Palla, Zürich H.F. Zeilhofer, Basel T. Göhring, Zürich S. Paul, Zürich N.U. Zitzmann, Basel Schweiz Monatsschr Zahnmed Vol. 119 10/2009 975 Research and Science Articles published in this section have been reviewed by three members of the Editorial Review Board Jürg Barben1 Water Quality Claudia E. Kuehni2 Jürg Schmid3 in Dental Chair Units 1 Head, Division of Paediatric Pulmonology, Children’s Hospital, St. Gallen A Random Sample in the Canton of St. Gallen 2 Institute of Social and Preventive Medicine, University of Bern, Bern 3 Department of Health and Key words: drinking water, water quality, practice hygiene, Consumer Protection, Head of Pseudomonas aeruginosa, Legionella pneumophila department of biology and microbiology, St. Gallen Corresponding author Dr. med. J. Barben Summary This study aimed to identify the aeruginosa was found in both water samples Leitender Arzt Pneumologie/ microbial contamination of water from dental in 6/76 (8%) of the DCUs. Legionella were Allergologie Ostschweizer Kinderspital chair units (DCUs) using the prevalence of found in both samples in 15 (20%) of the CH-9006 St. Gallen Pseudomonas aeruginosa, Legionella species DCUs tested. Legionella anisa was identified Tel. 071 243 71 11 and heterotrophic bacteria as a marker of pol- in seven samples and Legionella pneumo- Fax 071 243 76 99 lution in water in the area of St. Gallen, Swit- phila was found in eight. DCUs which were E-mail: [email protected] zerland. Water (250 ml) from 76 DCUs was less than five years old were contaminated Schweiz Monatsschr Zahnmed 119: 976–980 (2009) collected twice (early on a morning before less often than older units (25% und 77%, Accepted for publication: using all the instruments and after using the p < 0.001). This difference remained signifi- 2nd June 2009 DCUs for at least two hours) either from the cant (0 = 0.0004) when adjusted for manufac- high-speed handpiece tube, the 3 in 1 syringe turer and sampling location in a multivariable or the micromotor for water quality testing. An logistic regression. A large proportion of the increased bacterial count (> 300 CFU/ml) was DCUs tested did not comply with the Swiss found in 46 (61%) samples taken before use drinking water standards nor with the recom- of the DCU, but only in 29 (38%) samples mendations of the American Centers for taken two hours after use. Pseudomonas Disease Control and Prevention (CDC). Introduction Pseudomonas aeruginosa, which can be found in stagnant water (Govan et al. 1996, Saiman et al. 2003). The transmission of pathogens to patients during dental treat- Several previous investigations found that the water which ment has been a topic of discussion for years, which is why reached the DCU failed to meet drinking water standards. In dental unit water has been investigated again and again (Exner Switzerland there are few studies on this topic, perhaps because et al. 1981, Panagakos et al. 2001). Because irreversible damage the water quality here is believed to be good. One study from may be caused to teeth when using high-speed handpieces Bern showed that only 10% of DCUs complied with all criteria without sufficient cooling, water spray, both to clear the work- required for drinking water and that the tolerated margin of ing area and for cooling, is an indispensable component of the 100 microbes per ml was frequently exceeded, however, three modern dental unit. Aerosol from these instruments has not minutes rinsing was sufficient to guarantee the water quality only increased the danger of infection for patient and dentist, (Tonetti-Eberle et al. 2001). In recent years various efforts but also continually increased the germ count in the dental have been made and numerous methods of disinfection have surgery (Dombrowsky et al. 1980). In particular, bacterial bio- been investigated with a view to improving the water quality film formation in the dental chair units (DCU) presents a big hindering the formation of biofilm in DCUs (Wirthlin et al. problem and poses a risk of infection not only for dental staff 2003, McDowell et al. 2004). For this purpose, the American but also for immunocompromised patients or persons suffering Centers for Disease Control and Prevention (CDC) have recently from other severe diseases (Pankhurst et al. 1995, Williams et published new guidelines for infection control in dental health- al. 1996, Barbeau et al. 1998, Walker et al. 2000). Patients care settings (Kohn et al. 2003). with cystic fibrosis (CF), an inherited disease with thickened The aim of the present study was to determine whether the mucous in the lung, are particularly prone to infection with DCU water quality in the St. Gallen region of Switzerland met 976 Schweiz Monatsschr Zahnmed Vol. 119 10/2009 Water quality in dental treatment units Research and Science the Swiss drinking water standards or whether dental treat- were identified by sequencing the mip gene (Ratcliff et al. ment might pose a risk for patients with diseases such as CF. 2003). Statistical analyses: The data were analysed using STATA Materials and Methods (StataCorp. 2007. Stata Statistical Software: Release 10.0. Col- lege Station, TX: StataCorp LP). As the microbial count data Water samples were taken from a total of 80 DCUs in 40 ran- were not normally distributed, we used medians rather than domly chosen dental practices in the St. Gallen area. The sam- means to describe average microbial counts. Our main out- ples were taken either from the high-speed handpiece tube, come (dependent variable) was the proportion of water sam- the 3 in 1 syringe or the micromotor. The dentist decided ples with a microbial count above the cut-off (300 CFU/ml for where the sample was taken from, but the water was sampled total microbial count, 10 CFU/l for Legionella und < 1 CFU/ml twice at the same location first on a Monday morning, before for Pseudomonas aeruginosa). These values were given as per- the DCU had been used, and also after use for at least two centages with a 95% confidence interval (95% CI). In order to hours. The water was collected by the dentist, or by another determine whether the proportion of positive samples was member of staff, in a sterile 250 ml glass containing sodium associated with the age and type of DCU as well as the sam- thiosulfate to inactivate oxidising disinfectants. All samples pling site, the data were first cross-tabulated and then further were brought to the Department of Health and Consumer Protec- investigated using univariate and multivariate logistic regres- tion on the same day and were processed within 24 hours. The sion analyses. Statistical significance was tested using a Chi2 DCU type and age were recorded on a questionnaire. test for the cross-tabulation and Likelihood ratio tests for the The standard method for water quality determination in logistic regressions. Switzerland was used to determine the number of bacteria (aerobic mesophilic bacteria) as follows: one ml of water was Results transferred into a Petri dish with 25 ml sterile liquid methods Agar (Difco, 279740) which, once it had set, was incubated at Two 250 ml water samples were taken correctly from 76 of the 30 °C for 72 hours. Then bacteria present were counted as 80 DCUs tested and could be used for investigation. In two colony forming units (CFU) but not specified further. Accord- cases, too little water was collected in the bottle (< 200 ml). In ing to official Swiss hygiene guidelines for the drinking water another case, the second sample was collected too early, and supply, values below 300 CFU/ml are regarded as normal, but in another, the sample was stored for longer than 24 hours. Of pathogens should not be present (Eidgenössisches Departe- the 76 water samples, 20 were taken from the high-speed hand- ment des Innern 2005). piece tube, 38 from the 3 in 1 spray and 16 from the micromo- Pseudomonas aeruginosa was isolated and identified from the tor; in two cases the sampling location was not recorded.
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