CDC health alert update - Georgia outbreak and what you need to know

This article is the latest news on the progression of the CDC’s Health Advisory regarding the outbreak of mycobacterium in dental unit waterlines.Last Updated: June 27th, 2023 On October 31, 2022, the Center for Disease Control and Prevention (CDC) issued a Health Alert Network (HAN) Health Advisory urging dental practices to prioritize dental waterline maintenance. This alert was prompted by the discovery of a new cluster of suspected nontuberculous Mycobacteria (NTM) infections in children following dental procedures at a pediatric clinic. The CDC is actively investigating this situation.

What do we know?

Based on a case study presented at OSAP 2023 in Tucson, AZ, titled "Case Studies in Waterborne Pathogen-Related Infections in Dental Facilities," Kimberly Kirkland, a Master of Public Health professional at Pathcon Laboratories, revealed that a dental facility in Georgia reported thirteen cases of infection resulting from pulpotomy procedures between May and November 2021. These cases specifically affected children aged 5 to 10 years old. It's important to note that there is a possibility of additional cases emerging since mycobacterium can remain undetected for up to 400 days as we saw in the Anaheim Outbreak in 2016.During the investigation, it was discovered that the facility had ten chairs, four of which were designated for hygiene and six for procedures and treatments. The dental facility sought assistance from Pathcon Laboratories for an initial risk assessment in April of 2022. Pathcon conducted extensive sampling of both the potable water and dental waterlines, including testing all the operatories.

What happened next?

On April 1, 2022, a total of 59 water samples were collected, revealing concerning results. 93% of the samples tested positive for HPCs (heterotrophic plate counts), with 32% exceeding the recommended limit of 500 CFUs (colony-forming units). Moreover, Mycobacterium was detected in 95% of the samples.

Pathcon Laboratories conducted further investigations on the waterlines and identified that one of the chairs, equipped with an ultrasonic scaler, exhibited the highest concentration of HPCs (heterotrophic plate counts) at 600,000 CFU/ml. Additionally, among all the samples collected, it also showed the highest concentration of NTM (non-tuberculous mycobacteria) with 326,000 CFUs. This finding raised concerns about the potential source of contamination.

Promptly upon discovering these results, the dental facility reported the situation to the health department and ceased seeing patients. They took immediate action, implementing extensive flushing measures and introducing a Monochloramine System to the waterlines, which combined chlorine and ammonia. Monochloramine systems can aid in penetrating biofilms and kill or inhibit the growth of microorganisms to help reduce the risk of contamination. The advantage of using a monochloramine system is that it allows for continuous disinfection in the waterlines.

A second round of sampling was conducted by Pathcon on April 29, 2022, using 55 water samples. The results showed significant improvement, with only 42% of the samples testing positive for HPCs, and 5% exceeding 500 CFUs. The presence of Mycobacterium decreased to 38% (21 out of 55 samples).

Over the course of the next eight months, the dental facility continued regular testing of the water. Finally, on December 20, 2022, all the samples tested negative for Mycobacterium. To ensure control over the water quality, the facility had to provide three consecutive weeks of negative test results before resuming patient care.

In addition to the remedial measures taken, the dental facility implemented several preventive actions. To address potential sources of contamination, they took specific steps, such as eliminating “dead legs” in the waterline system. A “dead leg” refers to a section of piping that is no longer in active use or has very low water flow, providing an environment where water can become stagnant. Stagnant water can lead to microbial growth and increase the risk of bacterial contamination The facility removed sink aerators, discontinued the use of the ultrasonic scaler, and also installed a flush valve in the hot water storage tank to enhance the cleanliness of periodontic cleanings.

What about the office’s waterline compliance practices?

During the investigation, as revealed in Kimberly Kirkland’s presentation at OSAP 2023 in Tucson, AZ, the dental office stated that they had some waterline maintenance practices in place before the outbreak. According to their statement, these practices included the daily use of waterline treatment tablets, monthly cleaning of the waterlines, removing bottles each afternoon for overnight drying, and replacing filter cartridges every three months. However, it was also highlighted during the presentation that the facility was not proactively practicing routine waterline testing, routine waterline flushing, or addressing dead legs within the system.

It is crucial to note that this information is based on the statement provided by the Pathcon Laboratories during the presentation and should be verified for factual accuracy.

The recent outbreak of mycobacterium infections at the dental facility in Georgia highlights the critical importance of prioritizing dental waterline maintenance. Thirteen cases of infection in children required surgical procedures to mitigate their impact. The facility’s prompt response and implementation of remedial measures, such as extensive flushing and the use of a Monochloramine System, resulted in significant improvements in water quality over time.

To ensure patient safety, regular testing of waterlines is imperative, as undiscovered details within these cases could potentially emerge over time. This is why waterline compliance is essential for maintaining a safe environment for your patients.

Like Shannon Mills, DDS said, “We now know that there are health effects associated with water that does not meet guidelines when used in certain procedures. It is time for dentistry as a profession to take this seriously”. By taking proactive action, dental professionals empower themselves to provide the highest standard of care and create a safer environment for their patients.

What can YOU do to prevent dental waterline infections?

To ensure patient safety and minimize risks, dental professionals must proactively prioritize waterline maintenance. By regularly testing and flushing waterlines, as well as implementing proper cleaning and disinfection protocols, dental offices can actively eliminate potential hazards. Ongoing monitoring and adherence to established maintenance guidelines enables dental professionals to take control of their practices and create a safe environment for patients. It’s a call to action for dentistry to collectively embrace the importance of these preventive measures, actively safeguarding the well-being of their patients.

Self-education is a powerful tool in reducing exposure and contamination risks in dental practices. Being knowledgeable about infection control best practices, including waterline maintenance, is essential for every dental professional. Let’s support one another and prioritize patient safety together. Remember, this outbreak serves as a reminder to create a safer environment in your practice. Together, we can ensure the well-being of your patients and staff.

You’ve got this, and we’re here to help!

3 Simple Steps to Get Started

Make waterline maintenance easier by incorporating 3 simple steps to get started.

Step 1: Adhere to Waterline Maintenance Standards

It’s important to know what each group recommends or requires to ensure that your practice is following their guidelines carefully. Note that even if your State Dental Board does not have a formal regulation regarding dental waterline maintenance, they are obliged to follow the CDC recommendations as a part of “providing ordinary and reasonable care in a prudent and competent manner to be practicing within the standard of care” (Graskemper, 2004).

For instance, the CDC’s summary recommends dental professionals to “Use water that meets EPA regulatory Standards for drinking water (i.e., ≤ 500 CFU/mL of heterotrophic water bacteria) for routine dental treatment output water” (Dental Unit Water Quality, cdc.gov).

The CDC’s publication Guidelines for Infection Control in Dental Health-Care Settings — 2003 and the CDC’s Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care are also contain recommendations for best practices in dental care.

Step 2: Develop Your Practice’s Standard Operating Procedures (SOPs)

Creating effective and user-friendly procedures tailored to your practice is key to achieving optimal infection control. We understand that this process can be complex, but you don’t have to do it alone. Our team of experts has extensive experience in developing protocols for dental offices. Whether you need guidance on creating new SOPs or refining existing ones, we’re here to help. Reach out to our team via phone or email to get started and ensure that your protocols are practical, easy to follow, and aligned with the best practices in infection control. Together, we’ll establish a solid foundation for maintaining a safe and healthy environment for your patients and staff.

Step 3: Actively Monitor Dental Waterline Quality

Regularly evaluating the water quality in your dental lines is essential for maintaining compliance and ensuring patient safety. QuickPass and FLO are both great waterline testing options for all dental professionals who are looking to incorporate routine testing into their protocol. As Amanda Hill, RDH, wisely stated, “The great thing about dental unit waterline safety is there’s an easy way to test if you are compliant. And the only way to know if your protocol is keeping your patients and staff safe is to test!”

We know that this can be challenging with all you have on your plate, but that’s why we’re here to support you!

Don’t Tackle Waterline Compliance Alone

At ProEdge, we are dedicated to helping you establish a solid foundation in waterline maintenance. Our experienced team is here to guide you in building a simple, repeatable, and well-documented protocol that aligns with best practices. With access to an extensive database with over 100,000 testing samples, we can provide you with evidence-based insights and recommendations. If you’re ready to take the next step, we invite you to schedule a consultation with one of our safe water experts. Together, let’s reinforce your commitment to patient safety and create a seamless waterline maintenance process. The ProEdge Team is here to support you every step of the way. Contact our Safe Water Team at 888-843-3343 or email us at support@proedgedental.com.

Additional Resources:

Dental Unit Water Quality (cdc.gov)

RR5217 Dental Front.pmd (cdc.gov)

Infection Prevention & Control in Dental Settings | Division of Oral Health (cdc.gov)

HAN Archive – 00478 | Health Alert Network (HAN) (cdc.gov)

– For all oral surgical procedures, use sterile saline or sterile water as a coolant or irrigant.

ADA: CDC health alert highlights importance of maintaining, monitoring safe dental waterlines | American Dental Association

– For all non-surgical dental procedures, use water that meets CDC recommendations (i.e., ≤500 CFU/mL of heterotrophic water bacteria).

Dental Unit Water Quality (cdc.gov)

– Consult with the dental unit manufacturer for appropriate methods and equipment to maintain the quality of dental water.

Dental Unit Water Quality (cdc.gov)

– Follow recommendations for monitoring water quality provided by the manufacturer of the unit or waterline treatment product.

BESC; Presenter’s Script; Module 9. (cdc.gov)

– Discharge water and air for a minimum of 20–30 seconds after each patient from any device connected to the dental water system that enters the patient’s mouth.

Sources:

Kirkland, Kimberly. “Case Studies in Waterborne Pathogen-Related Infections in Dental Facilities.” OSAP 2023, 2023, Pathcon Laboratories, case study presentation.

Centers for Disease Control and Prevention. “Dental Unit Water Quality.” CDC, August 31, 2021, https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention-practices/dental-unit-water-quality.html