The Compliance Divas Podcast
Our podcast covers current topics such as infection prevention and control, OSHA and HIPAA compliance for dentistry. We discuss the latest regulatory information, answer frequently asked questions and give suggestions for dental practices to make compliance easy and sustainable. The Compliance Divas are a trusted source for consistent, accurate information based upon current guidelines, standards, science, and recommendations.
The Compliance Divas Podcast
#217 Think your ultrasonic scaler waterlines are clean? Think again!
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The Divas wrap up Dental Infection Control Awareness Month with a powerful conversation with two experts from Parkell Dental. This episode focuses on water quality and biofilm contamination in ultrasonic scalers. Learn about the difference between scaler waterlines and other dental waterlines, and how to conquer the biofilm challenge with Pure Clarity.
Resources:
- Dimensions of Dental Hygiene: Are Ultrasonic Aerosols an Infection Control Risk? https://dimensionsofdentalhygiene.com/article/are-ultrasonic-aerosols-an-infection-control-risk/
- MDPI - Pathogens: Legionella spp. in a Dental Office - Current State of Knowledge https://pmc.ncbi.nlm.nih.gov/articles/PMC12196102/pdf/pathogens-14-00512.pdf
- CDC Guidelines for Dental Unit Waterlines https://www.cdc.gov/dental-infection-control/hcp/summary/dental-unit-water-quality.html
Welcome. I'm Leslie Cannon. I'm Mary Gavoni. I'm Linda Harvey. I'm Olivia Wan, and together we are the Compliance Divas. Welcome to the Compliance Divas podcast. I'm Mary Gavoni and I will be the moderator for this very special episode. Dental unit water quality is very much on the minds of dental professionals these days, and most practices believe that they are doing a good job of protecting patients and themselves from water contamination and the aerosols produced while doing dentistry. But what about ultrasonic scalers that may not be attached to the dental unit? They might be freestanding. Are they tested along with the other water lines? Are they periodically shocked to help remove the accumulated biofilm? Our special guests for this episode will enlighten us as to why this is so important. So I would like to introduce our two very special guests from Parquell, David Mott and Dr. Mike Carter. David is the president of Parquel, an ADS Association for Dental Safety, formerly known as OSAP Super Sponsor, and we thank you for your support of our beloved organization. And Parkel is also a 78-year-old U.S. manufacturer of everything from Blue Mousse who doesn't love Blue Mousse. I have fond memories of Blue Mousse and taking impressions, and Predicta bioactive cement and restoratives, which is a very exciting development in restorative materials. And then, of course, the workhorse for our hygiene listeners out there, the TurboSensor Ultrasonic Scaler, which is the backbone of many dental practices. David has been with Parquell in an executive role for 11 years and has been intimately involved with the design and development of Parquel's products during that time. In addition, David is an attorney and has a graduate degree in microbiology. What a unique combination. So David's experience and education have converged with the dental waterline products we're about to discuss. And we welcome you, David, and we thank you for your expertise.
SPEAKER_03It's great to be here. Thank you very much.
SPEAKER_00Thank you, David. Now I'd like to introduce Dr. Mike Carter, who is a general dentist with more than 40 years of experience, a man after my own heart, running his own private practice, a graduate of NYU, who has also spent the past 15 years as the in-house dentist at Parquel, which is just an amazing role in helping develop materials. So he helps to shape and refine the products that dentists use every day. That feedback, that expertise of a practicing dentist is so important. Dentistry truly runs in his blood as his father and his wife are both dentists, making his career a family tradition. Over the last decade, Dr. Carter and David have worked side by side, combining their unique perspectives, but sharing the same passion, finding real needs in dentistry and creating innovative solutions to meet them. Wow. What an amazing skill set expertise that you bring to us today. So thank you, David, and thank you, Dr. Carter. So Leslie, we're going to start out with you, and you have a question for David.
SPEAKER_01Hello, David, and thank you again for being here. But could you please remind us why water quality is such a critical issue in dentistry? And what inspired you at Parkel to develop a product to address this issue?
SPEAKER_03First of all, it's so nice to be here. You know, I know Dr. Carter and I both have been big fans of this podcast for a few years here, and we're also extremely big fans of the work that you're doing through this podcast and elsewhere in terms of spreading the message of safe dental practice. So thank you. And we look forward to the conversation. The question of why waterline quality is such a critical issue in dentistry, you know, that's a great question. I know it's a question and a conversation you've had on this podcast before, but as manufacturer of ultrasonic scalers for almost 50 years and with a service center where we repair scalers, you know, hundreds of them a month, uh I think we could speak to it from a slightly different vantage point, which should be interesting. So dental unit water lines from 30,000 feet. You know, every dental office has a series of water lines. These come from either municipal water or they come from water bottles, you know, closed bottle systems, and they split off and they travel to essentially every treatment device in the office being used by staff on patients. This water enters the patient really in two different ways. If we're talking, for example, about ultrasonic scalars. The water enters the mouth of the patient during dental procedures, and then also it's it's inhaled by both patients and staff in the form of aerosols, which are generated by treatment devices, including ultrasonic scalars and during dental procedures. So now none of this would be a problem, and and none of it is a problem if the water lines and the water are clean. In other words, if the water meets the federal requirements for safe water to drink. And I think we all know you know the definition of safe, ingestible, drinkable water was set by the EPA almost 50 years ago. It was actually 51 years ago, 1974. Drinkable water is water that contains less than 500 colony-forming units of bacteria per milliliter. Patients, I would say, very reasonably assume that the water being used during their dental procedures is safe. And staff, I would, I would wager to say, assume that the aerosols that are in the dental offices in which they work is safe and free from bacteria and pathogens. Unfortunately, this is pretty far from the case, as as you've heard, and I know you as you've discussed, any water test lab will tell you, and I think some have told you on this podcast, and I could tell you, having seen many, many ultrasonic scalars on a daily basis in our own service department, that water and water line safety is still overlooked in terms of proper protocols for infection control. And this unfortunately seems to be the case in a very high percentage of U.S. dental offices. In fact, it's not uncommon to find bacterial counts in water. They're as much as hundreds of thousands of times higher than the federal standard for safe ingestible water. So it's a very large issue. And as I know you've reviewed, there have been large infection events in California in 2015, over 70 kids, and two outbreaks or in large infection events in Georgia in 2016, I believe 2022, impacting over 20 children, several other states, and even cases of serious respiratory infections and deaths amongst staff and patients in Europe, Spain, the UK, Sweden, France, Norway, pathogens which enter dental treatment devices through water lines and which form thick biofilms within these water lines and ultimately shed off bacteria and pathogens into procedural water and into procedural air in the form of aerosols, which then impacts staff and patients in two ways. Again, in the form of water, which can enter the patient's mouth during procedures, and in the form of aerosols. This is of heightened concern with ultrasonic scalars, which is what we manufacture. It's something we want to stress very clearly in this discussion is this is of heightened concern because of two reasons, which Dr. Carter will get a little bit more into. But briefly, scalers are by far the most likely to fail waterline testing. If you speak to any of the water labs that are in this space, they have a proclivity for gathering and holding on to bacteria within their internal water lines. Even those scalers which are on straws or tablets or whole office systems, they gather quickly and unless properly maintained. And on top of this, scalars generate a lot of aerosol. So when coupled together, you have a worst-case scenario where scalers have water that greatly exceeds safe bacteria counts, and now are throwing this water into the dental air in the form of an aerosol. So it's an area that's receiving a tremendous amount of our focus, and it's something we're seeking to address both with product offerings as well as through large educational efforts.
SPEAKER_01Well, thank you, David, for that great explanation. You know, it just brings up a quick memory. I've my father is a dentist, and when I worked for him as a teenager, this was before gloves and masks and clinical jackets and all the safety eye wear. I remember leaning into the mist of the ultrasonic scalar, they call it the Cavitron. And it was the only way to really cool down during a hot day where the treatment room had the patient, the doctor, and the overhead light. And now when I think back on that, that's some pretty scary stuff.
SPEAKER_03It certainly is. And so this wouldn't be an issue if those who use the scalars, if those who own the scalars, they test the water quarterly, you know, per ADS recommendations, and if they find a way to either filter out bacteria before it enters the scalar, uh, or have treatment straws or tablets, which might help suppress those bacterial levels. But unfortunately, back in the days that you're talking, neither one of those was really an option, was it?
SPEAKER_00No, it was not. And I have nightmares every time I hear you say that, Leslie, because I had respiratory infections all the time when I was a dental assistant. When I became a hygienist and was using an ultrasonic scalar, that was then in the days of wearing PPE. So I had some protection, but we do know that those ultrasonic scalars create some of the most aerosol. And it just makes me cringe when I go into an office pre or post-COVID, and I watch the hygienists wearing their face mask underneath their nose and just cranking on that ultrasonic scalar. I'm like, do you understand the risk that you're putting yourself at? So not a good thing. Dr. Carter, again, welcome. And what we'd like you to do is speak from a manufacturer's viewpoint, also with your dentist hat on. What is it about the ultrasonic scalar that really makes them so risky besides what we've already discussed?
SPEAKER_02Sure. But before I actually do that, let me also say, as a regular listener and a fan of your podcast, it's really very cool to be at the table with you both. So yeah, this is a great opportunity for us both. Dave just mentioned some of the reasons why scalars are important. So what I want to do with this question is dig a little deeper as to why scalar water lines specifically over other water lines require that special attention. And the interesting thing is most clinical staff don't even realize just how narrow dental unit water lines really are. And the reason is simple because they're hidden from view. The water lines are tucked inside larger hoses or built right into the equipment itself. But the actual water lines that feed an ultrasonic scalar are only about one-sixteenth of an inch in diameter. And putting that into perspective, that's about the thickness of a dime. When something carrying water is that narrow, frictional forces tend to dominate, giving bacteria more surface to cling to. Now, some in your audience may be sitting there thinking, hey, wait a minute, isn't the tubing the same size for the water lines that feed high-speed hand pieces and air water syringes? And you know what? They'd be absolutely right. But here's where the scalar is different in three important ways. First, the flow rate. A high-speed handpiece or an air water syringe pushes water through at around thirty to forty milliliters per minute. The scalar, on the other hand, moves water at only a rate of ten to fifteen milliliters per minute. So that's less than half the rate of the other two. And that slower flow means water lingers in the tubing, giving bacteria more time to attach and develop into biofilm. The second is isolation. The scalar often has its own separate water line, apart from the main lines that feed the syringe and the handpiece. So even if the rest of the chair is being treated, the scalar line doesn't automatically benefit. It needs its own focused management. And third, where it's used. Ultrasonic inserts spend most of their time in and around inflamed tissue that bleeds easily. That creates a direct pathway into the circulatory system for anything living in the water. So when you put all those things together, plus the fact that scalars generate more aerosols than any other instrument, it's clear why scalars can be such a concern. Because if the water line isn't clean, microorganisms can be delivered into the patient's bloodstream as well as become aerosolized throughout the operatory.
SPEAKER_00I am blown away. Those are things that I have never considered before, especially the flow rate. And that makes perfect sense that if the water is more stagnant or is in those water lines for longer, then there will be more accumulation of biofilm. Thank you for sharing that. And I think that we we tend to sort of listen to a lot of the chatter that's out there about water lines, but I love the fact that you really took that deep dive into having a better understanding of the science behind this because that is critically important.
SPEAKER_02Absolutely. And truthfully, one of the reasons we started to dive into that was because we wanted to try to figure out how long our pure clarity filters would last on a scalar. So we really had to kind of figure out what kind of a flow rate on average the water going through the filter will be. And it was actually quite surprising to me that the flow rate was so much less than it was with the other devices.
SPEAKER_00Very interesting. Leslie, I'm gonna turn it back over to you.
SPEAKER_01Well, this is where I'd like to ask David if you could just tell us a little bit about the solution to this issue that Dr. Carter has brought up. How is the pure clarity used to solve this problem?
SPEAKER_03Okay, so I'm gonna kind of walk you through a little journey, and I'm ultimately gonna get to that answer. A journey in terms of how we developed the the pure clarity. First of all, again, we manufacture many, many scalers, and there's uh hundreds of thousands out in the field. They're the backbone of a lot of dental offices. And we receive hundreds every month for service. And one of the things that we've been discovering, and I think we have fresh eyes in this regard, is an extremely high percentage of the scalers that we receive back for service has water, which we expel from the unit as a first step. But this water, I'm gonna hold up a file for those on this podcast, for those listening, can't see it. But trust me when I say that the water coming out of these scalars is far from clean. It essentially looks like pond water. And so when this issue of waterline contamination by bacteria and biofilm became crystal clear to us through the education of you all, but is what in addition to what we're seeing ourselves, what we looked at first was the filter that's already been included on all brands of scalers, magnetostrictive scalars, piezo scalers. There's been a filter included with all of these for four or five decades. And so, you know, and then and we could all recognize them, they're disk shape, or some people say UFO-shaped, and offices do replace them routinely. I know that because we sell them and we sell them in in very large quantities every year. So, what we did is we reviewed those filters, the filters that have been around for 50 years. Right away, you think, okay, that's I'm sure it's an outdated technology if it's been around for 50 years, but we we reviewed it in terms of what do they filter, what is their purpose. Really, of course, what we found out is what we expected. And these filters are only taking out large sediment, and they are doing nothing in terms of the smaller creatures that we worry about, that being bacteria, pathogens, uh, and those that are being associated with real health risks now. And so, what we did then was we sought to answer the question of what we could do, what would the ideal filter look like? You know, how could we upgrade this filter technology so that it's no longer just taking out large particles, it's taking out bacteria from a reductive perspective. And so, what we arrived at is truly a state-of-the-art chemical-free bacterial filter that that twists on, you know, lure lock fitting, just like the UFO disc filters, uh, onto any brand of scalar, a magnetostrictive or piezo, and which captures all bacteria and all pathogens, prevents them from passing through these filters for as for as long as six to twelve months at current flow rates. So they do not impact negatively the performance of the scalar in any way. So the filters are fully validated. During the validation, essentially pond water was fed through them. The bacterial count of this water that was fed into the filters was was quantified and it was extremely high. And then the assay coming out or the the filtrate coming of these filters, the bacteria count in those was was quantified and it was zero. It was it was zero. And so it it traps and prevents all bacteria, all pathogens from passing through. And it could frankly be outfitted to any dental unit waterline, anyone that you put a warlock on. But there was an additional problem. In addition, we had to address what to do about the bacteria and biofilm that's already in the scalar, because we want people to be able to upgrade to a bacterial filter, but there's no use putting a bacterial filter onto a scalar that's already been out in the field if it's already filled with biofilm. So we needed to find a way to ease the process for loading shock into scaling. And prior to pure clarity, there wasn't there are a few ways to get shock into scalers, particularly scalers that are plumbed directly to municipal water. Once they trace their water for their scaler, they'll see that it's still hooked to municipal water, even though the rest of their office is on a bottle system. And so what we came up with, in addition to the filter, you receive a shock syringe, which also is a lure lock fitting. It's it's only 20 milliliters. And really, it takes only about eight to 10 milliliters of shock solution to fully populate the internal water lines of a scaler. And so it's the easiest twist-on, twist-off method for loading shock into a scalar on the market. And so what the tagline that we've ended up with is shock then protect, because with this very small package, you you're capable of very easily loading shock into a scalar. And then, you know, once you've purged out that shock solution, verified that the water is now compliant, you put on a pure clarity filter and no new bacteria, no new pathogens able to pass through and to get into your scalar. So it's really something that we're excited about, and I really think it's something that might help out the industry.
SPEAKER_00I totally agree, David. And I, as a hygienist, my brain keeps going to okay, who are the patients that I am most likely to use my ultrasonic scalar on, and those that need some very serious debridment, those that have periodontal disease, that I want that lavage to help disrupt and flush out some of the bacteria, but I'm defeating the purpose if I'm introducing new bacteria, new pathogens into the mouth. So that filtration is amazing. And so you're addressing two problems at once. You're getting rid of the biofilm in the unit and then filtering everything from there on. So you really make it safe for your patients. And Dr. Carter, I think that maybe you had some comments that you wanted to share with us.
SPEAKER_02I would just like to add to some of the stuff that David just covered, because Parkel is writing a waterline story that applies to any scalar from any manufacturer. And it's not often we get to share that story on a platform like yours. I think we've established that scalars are the weak link in the waterline maintenance chain. And as Dave previously mentioned, as a scalar manufacturer, we see it every day when a unit comes back for service or maintenance because we get to peak inside those water lines. And what we find, more often than not, is that they're not being maintained properly. There's visible evidence of biofilm and bacterial contamination. Now, why is this the case? Well, we talked earlier about fluid dynamics of narrow water lines and their isolation from other devices. And as compliance consultants, you all have probably also experienced that even well-intended offices who think they're doing the right thing still struggle with keeping their scalar water lines clean. So one of our inspirations was that as a leading scalar manufacturer, it was important to help address this problem. And we also knew, based on what we were seeing firsthand, that the solution had to be practical, simple, and effective. And that holds true for both scalars already in service as well as new scalers about to be put into service. So let's see how pure clarity measures up on those three objectives. Is it practical? Pure Clarity treats the water closer to the endpoint of the waterline than any other product available. Now, why is that important? Because with Pure Clarity, you only need to maintain and shock eight feet of water line. If you're treating from a bottle, on average, it's about 16 feet of water line. And if you're still going from a junction box, you're talking about 24 feet of tubing. Is it simple? Less than 20 milliliters, as Dave just mentioned, of shock solution is needed to completely fill that 8 foot of line. That's easily done by loading the pure clarity shock syringe with any solution recommended by the scalar manufacturer, attaching it to the universal connector on the back of the scaler or the Lure Lock connector, and with just light hand pressure filling the line. And is it effective? The microporous membrane filter has proven so effective at blocking bacteria from passing through that the frequency of shocking is greatly reduced. And that's really the point. Parkel wanted a solution that fits into the reality of everyday dentistry, one that keeps patients safe, helps offices stay compliant, and does it all without adding more burden to the daily routine.
SPEAKER_00And what a beautiful summary of all the advantages of your product. I'm just so excited to be able to tell all the practices I work with about this, and obviously to point out the issue, and we have a great solution that makes sense. It doesn't add a lot of burden to your workday, and you can have safer water for your patients and for you. David, any final thoughts on your part?
SPEAKER_03You know, I just wanted to express again thank you. We are very much fans of this podcast and again of the work that you're doing. I mean, you're spreading critical information through this platform as well as through other platforms. And it's it's been a true pleasure. And we'll get there as an industry. You know, we will, as Dr. Carter said, we we see a lot. Um, we look under the hoods of the scalers, and at this point, I will tell you there's a good distance we we need to go. I speak with a lot of others within this space, and they will tell you the same thing. Um, but I think the more people that are engaged in in this subject area, and man, once you get engaged in this subject area, it is quite the rabbit hole in terms of there's a lot there. It's incredibly interesting. There's there's there's cool science, it's a public health issue, and I can't help but to bring it back to it's almost a Seinfeld line, and I've said it many times. You know, the the the current state of infection control for dental water lines offends me both as a manufacturer, it offends me as a patient, as the son of a geriatric mother, as the father of two young kids, and and it offends me as a lawyer. So I know by putting all of our efforts together, we could really help drive this to a to a safer place, which will be good for two subsets of people. I mean, really patients and staff.
SPEAKER_00Absolutely. Leslie, final thoughts on your part.
SPEAKER_01I just wanted to thank Dr. Carter and David for educating us, bringing this information into easily understandable, bite-sized digestible pieces. I know uh I appreciate it, and I've got new eyes with the ultrasonic scalar, and I know our listeners will appreciate this podcast as well.
SPEAKER_00Absolutely. I have never heard anyone talk about looking under the hood, as you so rightly said, David, that we think we're doing a good job and trying to urge people to test is one thing. But when we actually see inside those scalars to see that that pond water coming out, that we need to be very, very concerned. So thank you both for, as Leslie said, for educating not only us, but our listeners to dig deeper, follow that science, and look for practical solutions to these issues. We thank our listeners for tuning in at the Compliance Divas. We keep you up to date by navigating the regulatory world and help you keep on course with compliance. If you have questions, you can submit them by email to support at the compliancedivas.com. We will have a number of resources that will be in the show notes on your podcast app. And when you're finished listening to the podcast, if you would scroll down to the end and leave us some comments, leave us some feedback, and please give us a rating. So thank you for tuning in, and we hope that you join us on another episode of the Compliance Divas podcast.