Inside the Lines: What Dentists Need to Know About Waterline Safety

What are we going to do with our rhythm for testing? We know if we haven't been doing anything at all, three passes, a must. But is that going to be an office or is that going to be a lab? And then what are we going to do consistently after that? Welcome to Austin, Texas, and welcome to the Phil Klein Dental Podcast. What if the water flowing for your dental unit isn't as clean as you think? And how would you even know? We trust that if incoming water meets municipal standards, we're safe. But inside those narrow dental unit water lines, biofilm can build and bacteria can rise unnoticed. So what does that actually mean for your patients? Are we talking about minor contamination or something more serious? Could poorly maintained water lines contribute to infections like infective endocarditis in at-risk patients? What about respiratory illnesses like Legionnaire's disease or exposure to organisms like Mycobacterium abscessus, which has been linked to dental outbreaks? They aren't theoretical. They're real risks. In this episode, we tackle a critical question. Do you have a reliable waterline protocol? We'll cover why testing is the first step, how shock treatments work for both remediation and prevention, and how to build a simple workflow that keeps your water safe and documentation easy. Because every patient is exposed to that water, are you confident it meets the highest standard? Our guest today is Michelle Strange, a dental hygienist, educator, and founder of Michelle Strange RDH and Level Up Infection Prevention. She helps practices implement practical, real-world infection control strategies. This episode could change your approach to water lines, so let's dive in. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Michelle, it's a pleasure to have you on the show. Always great to be here. Yeah, and I do want to tell our audience that you did a great webinar in March of this year. Really good job. The title of that... is the Dental Unit Waterline Protocol for Success. I recommend all of our listeners to hop on to VivaLearning.com and check out Michelle Strange's webinar. She did a really good job. You'll actually get some humor in there because I believe, Michelle, you did that from your office. Yes. You locked the place up and in the middle of the live webinar, somebody rings your bell, if you do have a bell there or knocked on the door or whatever, and they forgot something. You want to give us a quick 30 second? Oh, I know. Gosh, yeah. True live thing happening there. I actually saw them walking up because I was sitting next to the window where the door is like right next to it. And I know that the previous patient before that had forgotten their toothbrush and like their kid came back to like just jumped out of the car and ran in and got it. And like you said, I had the place locked up. There was nobody else in there with me. So I know, live. Yeah, that was good though. No, that was certainly very entertaining. Oh, good. Yeah. So before we get into the actual topic in depth, Michelle, I do want to clarify for the audience the difference between a water bottle system that connects to the water line of your dental chair and also a cartridge straw system. And you talk about this a lot, but I'm not sure in any of our previous podcasts or webinars. You've actually explained that. Now, maybe everybody knows, but as an endodontist who practiced a long time ago, I had no idea what was going on. We probably just had municipal water coming in. But anyway. It's still a confusing topic. So I do think that this is a great time to kind of clarify some nuances to this because. there are people that are going to have their dental units tied into city water kind of you know and some people will even have the switch will which will go from city water to a bottle system i had that for years and then some will just be a bottle system and so what i mean by that is the actual bottle that you can pull off the dental unit and fill with your desired water usually tap water a lot of these dental units these days want tap water but You know, some people are still using distilled or maybe a reverse osmosis, maybe even ozone. So there's different sources, obviously, but that water bottle system is very important because that is how you're going to be able to apply your treatment or your maintenance. And we can break down the cartridge and straws in a second. or that's how you're going to shock if you don't have a bottle system we cannot do all those things and just as a reminder i say it often on the webinar it is not your water it is your water lines so even if it is coming from city water that is treated we still have to manage the water line so having a water bottle is so very important there is a world where your technicians whoever works on your units can come and retrofit that meaning they pull it off of the multi the city water and put a bottle on that right and now that so that bottle that water bottle basically needs to be treated with tablets in order to make that water acceptable for doing dentistry but in in lieu of the water bottle you also could use a cartridge straw system and that actually just drops into a water bottle right the same way yeah let me clear up some of that a little bit there because yeah so not in lieu of a water bottle but inside of a water inside of a water bottle you can have a cartridge the semantics gets a little confusing here because it could also be a blue intake straw is called a straw as well that does not have a medium in it that will actually treat the water so i want to make sure that offices are all saying the same verbiage when we are talking this so some people will say a straw and what they mean is the cartridge it's more of a harder tube that will then be attached to your bottle system that will deliver let's say for instance, silver ions that are treating the water as it goes through the system. Or in that bottle, you could put tablets using that blue flexible intake straw. So yes, you do need both of those, either one tablet or cartridge in a bottle in order to feed your water lines with some kind of treated water. The basic difference is how you treat the water, whether it's a cartridge straw system, or whether it's just tablets added to water. But both of those systems have tubing in it that draws the water out into your system. In the cartridge straw system, the straw is the tube. In the regular system, where you just, not the regular, but the simpler system, before the cartridge straw system came out, You just drop tablets into a water bottle and the tube in there pulls that water out into your chair. So either way, yeah, you're separating yourself from municipal water system and you're controlling what that water is as far as being decontaminated by how you treat it. But both systems have to be tested, shocked, and they have to be maintained. And we're going to be talking about that. Yes. So let's hit the first question. So most dentists assume... that the water coming out of their dental unit is clean and safe for patients. I did when I practiced. But what many dentists don't realize is that dental unit water lines can quickly become one of the most contaminated systems in the entire practice. So let me start with this. How big of a problem is dental unit water line contamination? And why should every dentist be paying closer attention to it? Our little dental units are just a breeding ground. because we have these tiny little tubes they're low flow um these water i mean they these lines and nooks and crannies and everything within the unit itself is a perfect breeding ground. If you ever question, I want you to think about your periodontal patient that has all the nooks and crannies. And if they are not coming in for their periodontal maintenance, which is, I call it your shock of the system, right? Think of how. like dirty and contaminated that is with biofilm and that's what we're dealing with in these lines. These tiny low flow plastic little tubings all throughout our lines. I used to call our ultrasonic bath like the cesspool of the office like it has just got everybody's gunk in that ultrasonic bath but I'm really starting to call like your dental unit water lines and your ultrasonic bath like the cesspool because it is just a breeding ground for these microbes and we do have a major problem in our industry it is something I think Shannon Mills called the dirty little secret of dentistry for years because we have not well we've been only kind of treating them maybe because I've been doing tablets for probably 15 years but I did not test and I did not shock I even had a heater on one of my units which is whoo talk about breeding but We have these like little lines and we're putting water into people's mouths and we don't ever look at it. Like how often do you put it into a cup and go, can I drink this kind of thing? Like, no, it's not. We're just putting it right through a handpiece or a water syringe. So even with all the teaching and education that not only you've done, but many other educators, dentists, hygienists, infection control specialists who talk about this, you still think. that it's in large part a major problem in dental offices in the United States? Oh, I definitely think that people believe that what they are doing is working. And when I say that, they're probably either putting a tablet or using the cartridge straw system, but they are not testing. And we know they're not testing because when we ask them and do these like ADS, the Association for Dental Safety did a survey and it was like less than 50% of the offices were testing. So like it is an issue. And when I go into offices, just maybe I was temping at one point, I was given training for certain things at some point. I'd ask them, what are y'all doing for your water lines? Hey. confusion, what do you mean? Not sure what that means. Or they'll tell me what they're doing for their suction lines because they confuse them, which I get. It's all kind of like next to each other. But yeah, I do believe that there are a lot of misguided people who, because they think that they're putting this tablet in there or whatever, that they're safe and they're keeping their patients safe. But you genuinely have no idea unless you are testing. And they believe they're doing distilled water and that's okay. And that's a whole other beast. a problem. Yeah. So when experts talk about proper waterline protocol, like you did in your webinar, they often describe it as test, shock and maintain. Now we'll be going through each step, Michelle. But before we do that, give us an overview of why the test, shock and maintain protocol is so important to waterline safety. Essentially, without doing all three, the office will inevitably fall into an infinite loop of failed test results that exceed 500 CFUs. So tell us about that. trifecta that is so critical. Yeah, and that's exactly what I call it, like your trifecta. These are the three things that are going to work together to make sure that what you're doing day in and day out is actually working. So we test, you will never know what's happening in your water lines unless you're testing. We are not working off of hopes and prayers as healthcare providers. We need testing. We sport test for our autoclave, right? Like we have chemical indicators for our packaging. We have a lot of these, like, quality assurance programs in place to make sure that, again, we're not working off of hopes and prayers. We're working off of facts. And the test is going to bring your facts. So you're not guessing. You're not hoping. You actually know what you do day in and day out is truly maintaining your dental unit water lines to keep them below 500 colony-forming units, which is the EPA's suggestion or recommendation guidance for safe drinking water. So testing is an absolute must. going to knock down that biofilm and maintaining or treating is what's going to maintain it throughout and keep it below that 500 colony forming units in between your shock and your test right so so doing those three things which you reference as being the trifecta which is a great name for it is is the critical thing because if without the other two if you do any one of the three and you don't use the other two you're going to get failures where that cfu is going to exceed 500 now Let's start with test protocol. The mindset of a lot of these dentists or people that are, whoever's running the infection control team, assistant staff, whatever, is that, you know, like you mentioned earlier, I'm using the tablets and I use it religiously or I'm using the cartridge straw system religiously. So I should be good because I keep putting fresh stuff in and I should be good, but that's not the case. So let's start with the test protocol. How often should practices realistically be testing their water lines? And what are the most reliable ways to do that in a busy dental practice? So if you have not been testing at all, or it's been a while since you tested, the ADA, or I'm sorry, ADS is the Association for Dental Safety's white page talks about a minimum of three passing tests a month apart. So start here right now, you're going to get your baseline, pass or fail. And then one month later, we're going to do another test. another month later. So bam, three months in a row. If you're pass, pass, pass on all of those, we can then go to a quarterly testing. If you're... failing and passing, I think you need to keep going until you've got three passes, monthly passes in a row. And then you go to that quarterly. And for me, I think that there's two types of testing that we can do. There is in-office. The ones that we're all probably very used to have been the paddle test of the past, right? Now we have a newer one out called Fast Check 15, which is giving us results in 50. whereas the paddle test was up to like 72 hours. So you still went days not knowing if you're truly having safe dental unit water for your patients. Then there's also mail-in tests. And so those that you take a sample and you put it in the mail, it comes with like ice packs and different things to make sure that we're preserving the quality of the sample. And they incubate that for about a week's time. And that's great because it's giving your slow growers, right? We're getting a real more detailed nuance to what is growing in those lines. I personally, once a quarter, will do a mail-in. because I want to know what's going on with my slow growers. And then monthly, I'm doing fast check because it's so easy. But I would also say at bare minimum, try once a year for your lab test so that you kind of have a real good idea of like what's going on in those lines. And then you could do throughout the year using something like fast check 15, which like I said, gives you sample or your results in 15 minutes. So nice and easy. Right. So we do that testing. Now, if an office. believes they are very compliant and they're doing everything according to the manufacturer's instructions. They're doing everything according to SLP of the practice, which is documented. But then they get a failure for just some ad hoc test. They get a failure. Has that happened to you? And what could be the possible reason for that? Yeah, I mean, that is... There's so many reasons. Human error is a big one. I would say this for like your spore testing too. It was put in the wrong part of your machine, your autoclave. Maybe you put too much water in your fast check 15, right? Or you didn't let it incubate long enough. You didn't follow the instructions for use. Human error is like a big reason for failure. And then I would say maybe somebody forgot the last time to shock a line that gets water. I think the slow speed handpiece is such a great example. for this like it gets water but not everybody uses water for it and so maybe six three months ago when you were shocking somebody just didn't do that one line well it can still be breathing and it can almost be like a feeder to the rest of the lines um that will kind of jump start that coder and floater situation in the biofilm so there there are definitely reasons even when you're doing all the right things we're humans we're gonna err that happens it's just important to have steps for remediation if you are failing. Okay, so let's talk about shock now. What exactly is a waterline shock treatment? Tell us what that means and when should a dental practice use this? So a shock is oftentimes either a different chemical than what you're doing to treat your lines every day or a stronger version of it. I won't speak to all products, but I'd say that's a pretty decent generalization. And what we're doing is we're trying to knock that biofilm down a little bit so that it doesn't have those seeds that will go out and start feeding and creating a bigger biofilm. I mean, it's the same thing in the mouth, right? your periodontal maintenance. We are busting up as much of that biofilm as we possibly can. We know we're not getting rid of bacteria like that. We just know that, but can we lessen it? So for our patients, there's less host response. And in our lines that throughout the days of using the treatment that we are able to let that low, low chemical keep that biofilm or the bacteria that's off seeding below 500 colony forming units. So that shock, tell us about how it's actually done and when it should be done as far as the frequency. And also, should you stay within the same system as far as the company that makes the test equipment, the shock equipment, and the maintenance equipment? We haven't got to maintain yet. We're going to talk about the maintain phase in a second. But shock treatment, if you're getting passing grades or less than 500 CFUs on all your testing, you're still shocked though. Yes. Yes. So that's the first part there, I would say. No matter what, I test and immediately shock. I do not even wait for my results because it doesn't matter. No matter what, I am shocking. It doesn't matter if my patient comes in and they have all threes in their mouth and no bleeding. I'm doing a perio maintenance that day, right? So it just, it does not matter. I am going to shock. And I assume when you shock, you're kind of tying up the operatory, are you not? A shock can take up an operatory depending on when you're doing it. A lot of them will be overnight sits. So, yeah, like if you're doing it in the morning, it might take up your operatory or you just do it in the evening. Or if, you know, everybody tackles it that 15th of the month, whatever it is. Right. I also just to speak to what like compatible products. So for instance, if I'm using the Sterisil cartridge straw system, I can use a Sterisil Citrusil. I know it's like a lot of words, but the Citrusil is the shock. I can actually put that tablet into the water bottle and suck it up through the cartridge or straw because those two products are compatible. If you're using other particular products and maybe you're mixing it up, for one reason or another, you do need to follow instructions for use explicitly because if you suck up a certain shock through a cartridge where that shock was not meant for it, you will ruin that cartridge. So a lot of money down the drain. To be on the safe side, if you're using a cartridge straw system from Stericel, it's advisable to buy the shock system that is compatible with that cartridge because you need the straw to pull the shock. into your dental unit right so you have to have that material go through the cartridge and straw you can't just put a water bottle in there with a tubing for the shock. Yeah. If you do not have Sterisil for whatever reason, you can take off your other cartridges and put what they call a dummy straw on, which is that fake blue, not fake, but it's a blue rubbery intake and put another type of shock through it. For instance, if I want to use the Citrusil product, but for some reason I am failing and I cannot figure out why, I would probably suggest you try something like Liquid Ultra. which is a very intense shock product. But I would tell you, take off that straw cartridge from Sterisil, put your dummy blue straw back on and shock through that. Do not do anything that is not compatible with your straws. Yeah, that makes a lot of sense. So how long of a time does the shock chemical have to engage with the water line in order for it to be effective? And does that mean that the chair is out of commission? I assume you do it overnight. And then what's the protocol for making sure that when the patient does resume using that chair, that clean decontaminated water is coming out of those lines. That's a great question. So yeah, let's say, for example, I am using my Sterisil straw cartridge system. I put my little Citrusil orange tablet in there. It fizzles once it's done dissolving. I suck that through the lines and I'm looking for the orange on the other side. So I'm going to pull it through any line that can get water. Again, going back to that slow speed, even though it's turned off, if it can get water, I'm pulling it through. And then once that orange goes through, I'm going to let that treated, shocked water sit in the lines overnight. I also like to remind people, please put some kind of sign, hang something. Let the world know that you are shocking these lines because they will need to be run with clear water. So for instance, if I'm still in that stericill citrus situation, I will dump the citrus sil from the water bottle the next day I will fill it with my tap water that I use on my unit and then I will put it back on and then run that those lines again I usually go about one minute to two minutes you always want to make sure you clear of all the orange first and then I kind of go about a minute after that personally but you could go as long as you want but you know after that orange is gone and you've got some water flushing through you usually pretty fine with it and then you're good to go so anything connected to that water bottle any dental tool or device or whatever you want to make sure that you're when you're doing the shock you're running those systems those devices those that equipment until you see that orange coming out of it right as soon as you see that orange coming out then you know it's in that line of that device and that's when you stop and then it's then it's the time factor that's helping you decontaminate and destroy as much biofilm that may exist there as possible. Exactly. Okay. So getting back to what you said, Michelle, about testing and then shocking directly afterwards and not waiting. So you're going to test, you're going to shock right away, then you're going to get your test results back. And most of the time, if not all the time, you're going to pass. But that crazy time where it comes back failure, you need to remediate. And since you already shocked, what do you do next as far as what we're calling remediation? You're at least saying, okay, in an effort to... that I failed this in three to five days. I'm going to test again. And then on day five, I've tested again. I pass. That's remediation complete. Okay. Let's talk about maintain. Once a practice has tested and shocked their lines, tell us what the word maintain really means as far as keeping water quality consistently within the safe standards. So it's your tooth brushing. It's your interdental cleaning for your patients that are in those perio maintenance cases. So for us, it would either be a tablet being placed, appropriate size tablet, because remember, we all have like large and small water bottles. So making sure that you have the enough tablet that will go into the water bottle and also making sure that it's for distilled water or for tap water, because sometimes there will be some nuances to that. That's one way of treating on a daily basis. There's also, like we've been saying, the cartridge or straw system. So the little tube that will stay on the line for however many days, like Sterisil 365, there's some that are for six months. So it really just depends on how often you should be changing these. And that will be giving you this continuous silver ion through the water line. So from the standpoint of compliance, let's talk about compliance. cost. I don't know the answer, but my guess is that the cartridge straw is more expensive than the tablets, but requires less compliance. Is that right? Yeah, I think that's a decent way. I don't remember the exact numbers for some of these straws. What do you use? What do you like to use? I use the cartridge because I have ADHD and I forget to put tablets in bottles sometimes. So, I mean, that's what I'm saying. If the cost was the same, why would anybody want to use the tablets if the cost was the same? I would only assume that it's less. the downside is you got to drop these tabs in every day. Yeah. The only time where I am still using tablets is on my mobile equipment because I will break a straw off or cartridge off if I pack it up incorrectly. So I still use tablets in that space, but on these stationary units, yeah, it's like a no brainer to me. But you have to add water though to the water bottle all the time, right? Because you're using, it only holds so much. Yeah. And you just constantly refill with the tablets where I think it got a little tricky is like, okay, I have like so much at the bottom. Can I go my full next patient or not? And then it's like, well, that's money if I dump this. But then if I add water in another tablet, that's too much. Like, yes, it gets a little. I'm sold on the cartridge straw. Yeah, I'm sold. Okay. I don't have a practice, but I'll still buy it. I'll just play with it. So for busy dental teams, what is the easiest way, Michelle, to implement a streamlined workflow so that, I mean, it's all about compliance. You've mentioned before in your lectures that the water lines in a dental practice is the canary in the coal mine. Because if you're not compliant with getting that water line successively... Where else are you missing? Right. If you're not passing that test over and over and over again, sometimes you're failing, sometimes you're passing. That means that you're... You're not following SLP or you don't have someone dedicated that's held to account like an infection control coordinator, which I know you're a big fan of. So what recommendations would you make to a practice in order to make sure that you've optimized compliance and that you're moving in the direction where you're going to be able to control the biofilm in your office where you don't have to worry about it? so i would say like you mentioned an infection control coordinator first and foremost have somebody that is going to champion this they are going to take lead and they are going to read the instructions for you so they're going to figure out the testing and what products you want to use because it's if you've not if you're not doing anything at all i think it's overwhelming if you already have stuff it's overwhelming because you're like well are these things right and compatible so have somebody that is going to be like yes i'm ready to nurture out on this safe. I wouldn't want to drink my water right now without knowing. And then from there, I think you need to start with your dental unit water, or I'm sorry, your dental unit's instructions for use. Go see if your actual dental unit has any guidance. They might tell you. If they don't, then I would say, okay, what are, what do we have capacity for? Is it tablets? Like, no, like we have people like me that will, while I'm filling up the water bottle, my brain is already gone. oh my gosh i forgot to write up that last chart let me go do this and i forget to put it in the tablet right so then you're going to say okay we're going to go with a cartridge straw system do we want to have compatible products you know or are we okay with somebody knowing that there might be an extra step of taking that straw cartridge off and then putting the dummy straw on to bring up that shocked water And if you're like, no, less steps, the better, then I think it's easy. You can start finding those compatible products. And then final piece would be, I'd say like, all right, what are we going to do with our rhythm for testing? We know if we haven't been doing anything at all, three passes, a must. But is that going to be in office or is that going to be a lab? And then what are we going to do consistently after that? And I do want to mention that if our listeners want more information on protocol, on testing, SolMedic. has a great website, S-O-L-M-E-T-E-X. They're the owners of Sterosyl. Go to solmetics.com. That's S-O-L-M-E-T-E-X and look for Sterosyl. And then you can just a couple more clicks and you'll find Sterosyl Safe Water Testing Protocol. There's a PDF on that plus many other links. What happens if you get a failure? All the protocol that you need. So check that out. It's a really good resource. Last thing I want to ask you before we wrap it up, and it's been really a good discussion, documentation. To what extent do we need to adhere to documenting everything we're doing? Because if anything happens, like Legionnaires, what are some of the diseases that endocarditis mycobacteria yeah all of those yeah um so documentation is important if i mean it's just like everything if you didn't document it you didn't do it and that's if i was an auditor coming into your practice from the state board or there was a whistleblower situation and the public health department is coming in there or like we saw in anaheim with the little kiddos and jonesborough georgia epidemiologists found these things and like they they brought in the public health department so if you need to be able to prove Where are your SOPs? Where is it written? How are we doing this? How are we going about it? Because if it's living in somebody's brain, I'm going to tell you right now, then it doesn't exist. It doesn't exist if I'm an auditor. Yeah. No, it's very important because the disgruntled employee could come back and really haunt a dental practice owner, destroy a dental practice owner. Yeah. And Michelle, one last thing. What about pulpotomies? What kind of water? should our dental clinicians be using for pulpotomies. That is sterile water all day, every day. And the CDC has very clear guidance on what constitutes a sterile procedure or a surgical procedure where we should be using sterile saline or sterile water through its own delivery system. And I want to throw out this because some people will say, well, I use sterile water, but I put it in the water bottle that then goes through the water lines. And again, at the top of this, I said it is not your water. It is your water lines. You could put sterile water through there. I don't remember who said this, but if you're listening, please tell me. can quote you but they said it's like putting glacier water through a mud puddle and thinking you're going to get glacier water on the other side yeah that's very true yeah a lot to keep in mind like we'd like dentists like dentists don't have enough and hygienists and assistants don't have enough to think about as a practice owner now i'm like it's a lot to keep up with and i'm constantly updating you have your own dental practice which is a dental hygiene practice right Correct. What state is that? Colorado. Colorado has allowed hygienists to own practices since the 80s. Well, I hear it's a beautiful place to live and it works out for you for your career. Yeah, so. Michelle, thank you very much for your time. I want to thank you for your contributions to our show. I'm proud to say that our show is growing in popularity. We're one of the most popular clinical podcasts in dentistry right now, and it's certainly due to our great guests like you, and we're going to continue to bring relevant clinical information and practice management information to our listeners as we move forward with future episodes. Have a great evening, and thanks so much for joining us. Thank you so much for having me.