Journal of Hospital Infection 113 (2021) 187e188
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Journal of Hospital Infection
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Letter to the Editor
Microbial contamination of dental
unit water lines e a matter of
following instructions
Sir,
Recently Volgenant and Persoon reported good quality of
the water from dental unit water lines (DUWLs), meeting the
Dutch requirement of
100 colony-forming units per millilitre
(cfu/mL) by continuous disinfection with hydrogen peroxide
(0.02% H2O2) [1]. We here present a similar prospective
observational study carried out at the Dental School, Umeå,
Sweden, and public dental clinics (PDCs) in the surrounding
county, starting in 2007 and completed in 2016. Each clinic was
recommended to send annually one microbial sample to the
clinical laboratory at the Dental School for determination of
heterotrophic micro-organisms in the DUWLs. The study was
focused on whether the quality of water fulfilled the guidelines
of the National Food Agency, Sweden, for approved level of
drinking water, <100 cfu/mL [2].
The water was disinfected by sodium dichloroisocyanurate
(NaDCC; Aquatabs; Medentech Ltd, Wexford, Ireland) [3]. One
Aquatab generated 2.4 ppm chlorine (free and bound form,
50%/50% at pH 7.2) when added to 1 L water in a bottle con-
nected to the DUWL. The chlorine-containing water was con-
tinuously delivered by compressed air. The samples were
analysed at the clinical laboratory and the clinics were
informed of the results. In case of heavily contaminated DUWL,
the disinfection was repeated with a five-fold higher chlorine
concentration (five Aquatabs, 12 ppm). In addition, samples
from 25 new dental units were analysed for the presence of
heterotrophic micro-organisms immediately after installation
and before use. Bacterial species collected from these samples
were identified by 16s rRNA gene sequencing [4].
The results have previously been presented [5]. During the
10-year observation period (2007e2016), 3358 samples were
analysed: 1696 from the Dental School and 1662 from PDCs. The
proportion of samples from the Dental School containing high-
quality water were 89% except for year 2013. The corre-
sponding proportion of samples from the PDCs declined from
78% in 2007 to 62% in 2014 followed by an increase to 92% in
year 2016 (Figure 1).
The reasons for the varying adherence to the recom-
mendation differed, especially among PDCs, e.g. lack of
knowledge on the risk of waterborne infections, supplied
instructions were not followed, or lack of time or resource.
https://doi.org/10.1016/j.jhin.2021.04.013
0195-6701/ª 2021 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
100
90
80
70
Samples (%)
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10
Year
Figure 1. Proportion (%) of samples from dental unit water of the
Dental School, Umeå (black bars) and public dental clinics (grey
bars) that fulfilled the water quality standard during the 10-year
observation period (2007e2016).
During the period 2015e2016, discussions were conducted with
the staff of PDCs, which may explain the improvement
observed. In 2016 the samples from 90% of units demonstrated
high-quality water (Figure 1). The DUWL was recommended to
be filled with increased concentration of chlorine (12 ppm)
during vacation. This was also proposed for weekends.
The limit-value set for the number of heterotrophic micro-
organisms in portable drinking water varies between coun-
tries, from 100 to 500 cfu/mL. Cfu values between 100 and 500
were only observed in w5% of all collected samples during the
whole observation period. When values were found within this
range, the clinics were recommended not to take immediate
steps, but to put it on ‘observation’, awaiting the sampling
later in the year. The limit-value should not exceed 500 cfu/
mL, above which a risk may exist for formation of extensive
microbial biofilms.
The presence of heterotrophic micro-organisms in the DUWL
of the 25 newly delivered pieces of equipment showed that 23
of them contained >1000 cfu/mL, and, in the remaining two,
w500 cfu/mL were detected. High counts of Gram-negative
aerobic rods were observed, the flora dominated by Cupravi-
dus metallidurans and Sphingomonas parapaucimobilis. After
the decontamination with chlorine solution (12 ppm), all
samples showed values <100 cfu/mL.
The results of the investigation by Volgenant and Persoon [1]
and the present study show that good quality of water in the
DUWL with levels of contaminating heterotrophic micro-
organisms <100 cfu/mL can be produced by continuous dis-
infection. The varying adaptability observed among certain
188 Letter to the Editor / Journal of Hospital Infection 113 (2021) 187e188
clinics in our study indicates the necessity of regular follow-up.
Experience reveals that this is facilitated by a checklist. The
recommendation for sampling DUWLs should include new
dental units before use.
In water, NaDCC (Aquatabs) produces a stable and neutral-
pH solution, which may explain why no corrosion of the metal
instruments or of the pipes was observed [6]. Further, when the
procedures were correctly performed, no accumulation of
biological material (clogging) was observed.
NaDCC is accepted as an effective chlorine compound in
water disinfection and approved by the World Health Organ-
ization [3,7]. The microbial quality of the DUWL water was in
accordance with the recommendation of the National Food
Agency for drinking water [2] provided that continuous clean-
ing and control of the unit was carried out. The equipment
required is simply connected to the existing dental unit.
During the whole observation period no infections or other
inconvenience related to the DUWL were reported among staff
or the patients. The equipment required is simply connected to
existing dental units and the working costs are low.
Conflict of interest statement
None declared.
Funding sources
None.
References
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dental unit water lines at a dental school. J Hosp Infect
2019;103:e115e7. https://doi.org/10.1016/j.jhin.2018.11.002.
[2] National Food Agency, Sweden. Livsmedelsverket, bilaga 2 till
SLVFS 2001:30, gränsvärden och parametervärden, LIVSFS. 2017.
p. 2.
[3] Clasen T, Edmondson P. Sodium dichloroisocyanurate (NaDCC)
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[5] Claesson R, Edwardsson S, Bäckman N. Microbial contamination of
dental unit water lines e a matter of following instructions.
Tandlakartidningen 2019;111:64e9 [published in Swedish].
[6] Pinto G, Rohrog B. Use of chloroisocyanurates for disinfection of
water. J Chem Educ 2003;80:1e4.
[7] Lantagne DS, Cardinali F, Blount BC. Disinfection by-product for-
mation and mitigation strategies in point-of-use chlorination with
sodium dichloroisocyanurate in Tanzania. Am J Trop Med Hyg
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R. Claessona,*
S. Edwardssonb
N. Bäckmana
a
Department of Odontology, Umeå University, Umeå, Sweden
b
Faculty of Odontology, University of Malmö, Malmö, Sweden
* Corresponding author. Address: Umeå Universitet
Institutionen för odontologi, 901 87 Umeå, Sweden.
Tel.: þ46 703090126.
E-mail address: rolf.claesson@odont.umu.se (R. Claesson)
Available online 21 April 2021