Fi march18

A par tnered publication with Dental Sales Pro • www.dentalsalespro.com

For Dental Sales Professionals

Waterline Compliance Proper waterline disinfection ensures a safe patient visit

March 2018

© 2018 Crosstex 2/27/2018 CTX6754

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MARCH 2018

Editorial Staff Editor Laura Thill lthill@sharemovingmedia.com Managing Editor Graham Garrison ggarrison@sharemovingmedia.com Founder Brian Taylor btaylor@sharemovingmedia.com Publisher Bill Neumann wneumann@sharemovingmedia.com Senior Director of Business Development Diana Craig dcraig@sharemovingmedia.com Director of Business Development Jamie Falasz jfalasz@sharemovingmedia.com Art Director Brent Cashman bcashman@sharemovingmedia.com Circulation Wai Bun Cheung wcheung@sharemovingmedia.com Associate Editor Alan Cherry acherry@sharemovingmedia.com First Impressions Digital Edition is published monthly by Share Moving Media 1735 N. Brown Rd. Ste. 140 Lawrenceville, GA 30043-8153 Phone: 770/263-5257 Fax: 770/236-8023 www.firstimpressionsmag.com First Impressions (ISSN 1548-4165) is published monthly by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2018 by Share Moving Media. All rights reserved.

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Waterline Compliance Proper waterline disinfection ensures a safe patient visit

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Evacuation line maintenance Quickbytes

Technology news

Health news and notes

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Waterline Compliance

Proper waterline disinfection ensures a safe patient visit Improperly or poorly treated waterlines can place dental patients and staff at risk for infection, as well as create a liability risk for the practice. Some dentists may believe they are taking sufficient steps to reduce the risk, when, in fact, they are not. Using distilled water, cleaning bottles daily and refilling them with fresh water, and installing filters are not enough, according to experts. And, while waterline cleaner tablets provide a good start, total compliance is required each time the water bottle is filled, and often the practice doesn’t follow up to ensure tablet protocols are followed consistently.

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Once the source water – whether it is tap, filtered or distilled – reaches the narrow bore tubing of the dental unit waterlines, a perfect storm for biofilm growth develops, notes Leann Keefer, RDH, MSM, director, educational and professional relations, Crosstex. At the same time, microorganism counts exceeding the recommended 500 CFU/mL in the DUWL conflicts with the standard best practices of infection prevention and control. “Waterborne pathogens exist in all forms of water that are not sterile, including distilled,” she says. “To quote a highly respected colleague, Dr. John Molinari, ‘If you’re not doing anything to treat the dental unit water, it’s contaminated!’” Ignoring water line treatment is neither ethical nor acceptable, she adds.

“Dental unit waterlines (DUWL) must be effectively and efficiently treated to maintain acceptable safe and approved colony-forming-unit (CFU) counts,” Keefer continues. “For the past 50 years, Crosstex has been committed to focusing on safer patient care through innovative, high-quality solutions to ensure maximum compliance, in addition to offering an outstanding patient experience. It is critical for a client to understand the science behind the product, as well as following the validated product instructions for use (IFUs) for best performance.”

Indeed, the performance of a product is only as good as the accuracy of implementation according to the product IFUs, Keefer continues. “Compliance with DUWL treatment and the manufacturer’s IFUs is an important safety issue for the patient, staff and practice. The IFUs address the comprehensive DUWL treatment protocol, which may include the product as well as issues of frequency related to shocking recommen– Leann Keefer, RDH, MSM, dations and monitoring of CFU director, educational count. If a practice is only imand professional plementing one of three recomrelations, Crosstex mended steps or compromises on the frequency of treatment, the product is not being used in accordance with the IFUs.” (Daily-use products have a detailed list of protocols, which must be followed daily, weekly and quarterly to assure effective treatment outcomes.)

“Waterborne pathogens exist in all forms of water that are not sterile, including distilled.”

Waterborne opportunistic pathogens in DUWLs While some organisms have been identified in dental unit water as a result of back-flow from patients (oral microorganisms) the majority of microbial species found in DUWL output water are Gram-negative aerobic (without oxygen) heterotrophic (live off of others/carbon loving) mesophilic (heat loving) environmental (waterborne) bacterial species.

These opportunistic waterborne bacteria attached to the inner-surface of the tubing with an insoluble slime layer.

As the microorganisms grow and multiply, they create a more complex and potentially pathogenic environment.

Eventually pieces of the biofilm may break off and be carried through the dental tubing via the waterflow eventually delivered to the patient’s mouth.

In the past it was recommended to flush dental waterlines at the beginning of the clinic day for several minutes to reduce the microbial load. However, studies have demonstrated this practice does not affect biofilm in the waterlines or reliably improve the quality of water

used during dental treatment. Therefore, this has not been recommended since the publication of the CDC Guidelines for Infection Control in Dental Health-Care Settings in 2003. It is still necessary to discharge water and air for a minimum of 20 to 30 seconds after each patient, from any device connected to the dental water system that enters the patient’s mouth (e.g., handpieces, ultrasonic scalers and air/water syringes). This procedure is intended to physically flush out patient material that might have entered the turbine, air or waterlines. Even though the initial flush of the day is no longer indicated, it’s still a good idea to perform a quick flush of the lines before each patient to ensure everything is working (e.g., that the air/water syringe is attached correctly and water/air is flowing) before beginning patient treatment.

(Reference: Centers for Disease Control and Prevention (CDC), Guidelines for Infection Control in Dental Healthcare Settings, 2003. MMWR 2003; 52(No. RR-17):1–66.

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WATERLINE TREATMENT

Addressing best practices As a leader in infection prevention and control, Crosstex is committed to scientifically based programming to address best practices of infection prevention to provide a safe dental visit for the patient, clinician and the practice, says Keefer. Indeed, the company is a big believer in providing its dental customers with strong educational programs and sound solutions to help them protect their patients and staff.

There are several DUWL treatment options available to dentists, including: • I ntermittent. Routine chemical shocking protocol.

• Continuous. Tablet protocol.

• Automated. Cartridge delivery protocol.

“While each method, used in compliance with IFUs, can be effective in managing CFU count, automated treatment with the annual installation of a Crosstex DentaPure® cartridge provides continuous treatment for dental unit waterlines, reducing the need for daily or weekly intervention,” says Keefer. “DentaPure cartridges reduce staff time while increasing compliance with protocol, decreases the incidence of human error, and reduces the exposure of the staff to potentially caustic and toxic chemicals.” Together with DentaPure cartridges, Crosstex Liquid Ultra® Solution helps ensure compliance with EPA standards for potable water, she adds. “DentaPure cartridges are EPA registered to provide water ≤200 CFU/mL. And, when used as directed, Liquid Ultra is EPA registered to provide water ≤500 CFU/mL and it reportedly is the only EPA approved in-line product that kills biofilm bacteria,” she says.

By providing educational resources to clinicians and distributor field sales reps and service technicians, and by arming sales reps with patient resources to share with customers, “Crosstex has created educational touchpoints in every arena of safe dental unit waterlines,” says Keefer. “Crosstex is an AGD PACE-approved provider with CEU programs at national meetings and on-site practice-based learning events, and through VIVA Learning for live and on-demand CE webinars. Our Client Care team and educational toll-free STERILE

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Helpline (1-8558-STERILE) are ready to address both clinical and regulatory questions.” (Visit http://crosstexlearning.com/training.asp for the complimentary on-demand DUWL CE webinar.)

Easy maintenance Dentists appreciate the value of infection control protocols, including waterline treatment. But, some may express concerns about managing the compliance process and maintaining records. Once installed, however, the DentaPure cartridge requires no monitoring or shocking for 365 days, or 240L of water usage if records are maintained, notes Keefer. “If an office is concerned about monitoring CFU counts, we recommend independent testing by an outside laboratory,” she says. “For offices that are concerned that the iodine level stays within the range provided in the DentaPure cartridge IFU, Crosstex offers iodine test strips.”

Testing frequency – both for CFU – Leann Keefer counts and iodine levels – varies by practice, she adds.

“Dental unit waterlines (DUWL) must be effectively and efficiently treated to maintain acceptable safe and approved colony-formingunit (CFU) counts.”

Crosstex strongly recommends the following best practices in conjunction with use of its DentaPure cartridges and Liquid Ultra™ Solution: • Flushing for 20 to 30 seconds between patients.

• Sterilizing all handpieces after each use.

• Emptying independent water bottles nightly and setting them upside down to dry to avoid biofilm growth from untreated water remaining in the bottle.

• Wiping down the outside of the cartridge with a clean paper towel before replacing the bottle.

• Filling bottles with fresh water (tap or distilled) each morning before each use.

Editor’s note: All DentaPure claims based on use with potable water.

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WATERLINE TREATMENT

Evacuation line maintenance

Clean evacuation lines e nsure that suction lines are safe and fully functioning. Proper maintenance requires only

a small time investment on the part of the dental staff. By consulting with the manufacturer to ensure proper cleaning protocols are followed and the right cleaning products are used, suction lines will remain free of debris build-up, the suction flow will be uninterrupted and patients will receive the best possible care.

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Start a discussion In recent years, more cleaners have become available that feature a neutral pH, making them compatible with the office’s amalgam separator. Natural ingredient-based products have also been introduced and will be further evaluated for use in the next several years.

Still, some dentists have been reluctant to use them, objecting to the time investment and the risk of spillage. In addition, dentists might object to the cost of the cleaner or the need to adjust to a new dosage when switching to a new product. However, cleaning suction lines daily for both dry and wet vacuum systems is necessary to remove and prevent debris build-up and ensure proper suction flow.

Distributor sales reps can show their customers which solutions are most economical

One should clean the HVE system at the end of the day by evacuating a detergent or water-baseddetergent disinfectant through the system.

by breaking down the actual cost per cleaning. They should also review the product label and instructions to ensure the practice uses the cleaner appropriately. Generally, the use of a nonfoaming cleaner is recommended for use with dry vacuums, as foam cleaners tend to leave the turbine coated with residue and debris, leading to lower performance, loss of suction and eventual pump failure.

Sales reps can initiate a discussion of evacuation line maintenance with their dental customers by asking: • “Have you noticed a decrease in suction?”

• “How often do you clean your evacuation lines?”

Dental providers should be aware of CDC recommendations to keep suction lines disinfected daily in case backflow occurs when using a saliva ejector. For more information visit https://www.cdc.gov/oralhealth/infectioncontrol/faq/saliva.htm.

In addition, reps can direct their customers to the book Infection Control and Management of Hazardous Materials for the Dental Team, which states: High-volume evacuation (HVE) during the use of rotary equipment and the air/water syringe greatly reduces the escape of salivary aerosols and spatter from the patient’s

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WATERLINE TREATMENT mouth, which reduces contamination of the dental team and nearby surfaces. One should clean the HVE system at the end of the day by evacuating a detergent or water-based-detergent disinfectant through the system. One should not use bleach (sodium hypochlorite) because this chemical can destroy metal parts in the system. One should remove and clean the trap in the system periodically. A safer approach, however, is to use a disposable trap. These traps may contain scrap amalgam and should be disposed of properly. The dental team member must wear gloves, masks, protective

Disinfection of the trap by evacuating some disinfectantdetergent down the line, followed by water, is best before one cleans or changes the trap.

eyewear and protective clothing when cleaning or replacing these traps to avoid contact with patient materials in the lines from splashing and direct contact. Disinfection of the trap by evacuating some disinfectant-detergent down the line, followed by water, is best before one cleans or changes the trap.

Resource: Miller CH. Infection Control and Management of Hazardous Materials for the Dental Team, 5th edition. Elsevier/ Mosby Publishers. Page 181.

Editor’s note: Sponsored by Air Techniques.

Dental effluent guidelines Mercury pollution is widespread and a global concern that originates from a number of sources, including dental offices. In fact, dental clinics are considered to be the main source of mercury discharges to publicly owned treatment works (POTWs), according to the Environmental Protection Agency (EPA). According to EPA estimates, approximately 103,000 dental offices use or remove amalgam in the United States, and almost all of these send their wastewater to POTWs. Furthermore, dentists discharge approximately 5.1 tons of mercury each year to POTWs, most of which is subsequently released to the environment.

from the POTW through the incineration, landfilling or land application of sludge, or through surface water discharge.

Amalgam separators are regarded as a practical, affordable, available technology for capturing mercury and other metals, before they are discharged into sewers that drain to (POTWs). Once captured by a separator, mercury can be recycled.

In July 2017, the EPA passed its final rule specific to Best Management Practices for Dental Amalgam Waste, prohibiting the use of bleach or chlorine-containing cleaners that may lead to the dissolution of solid mercury when cleaning chairside traps and vacuum lines. The rule says, “…vacuum lines that discharge amalgam process wastewater to a POTW [publicly owned treatment works] must not be cleaned with oxidizing or acidic cleaners, including but not limited to bleach, chlorine, iodine and peroxide that have a pH lower than 6 or greater than 8.” (40 CFR 441.30(b)(2)).

EPA expects compliance with this final rule will reduce the discharge of mercury by 5.1 tons each year, as well as 5.3 tons of other metals found in waste dental amalgam to POTWs. For more information visit the EPA website: https://www.epa.gov/eg/dental-effluent-guidelines.

Mercury entering POTWs frequently partitions into the sludge – the solid material that remains after wastewater is treated.

Mercury-containing amalgam wastes generally find their way into the environment when new fillings are placed or old mercury-containing fillings are drilled out and waste amalgam materials that are flushed into chair-side drains enter the wastewater stream. Mercury entering POTWs frequently partitions into the sludge – the solid material that remains after wastewater is treated. Mercury from waste amalgam therefore can make its way into the environment

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Editor’s note: Sponsored by Air Techniques.

SPONSORED BY STERISIL

Dental Unit Waterlines: Municipal Tap Water and Why it Should be Avoided

BY JEROD MENDOLIA, MARKETING ASSISTANT, AND REID COWAN, DIRECTOR OF MARKETING, STERISIL

It’s no secret in 2018 that dental unit waterline (DUWL) cleanliness is important. Every trade publication, tradeshow and continuing education summit offers some sort of crash course on the subject. The bacteria problem is widespread and omnipresent regardless of the practice type or equipment employed. If it runs water, the potential to be a problem exists. Given their nature, dental waterlines will grow bacteria beyond the 500 colony forming units per milliliter drinking water standard without some level of shock and maintenance.

Opportunistic bacteria and the subsequent biofilm they produce are everywhere in the natural world. Every dental unit in use today employs a network of tubing to deliver both air and water to the handpieces. The typical tubing used in a dental chair is narrow in diameter and low in volume. This proportional relationship means the internal surface area is much greater relative to the volume of water flowing through the tubing. The smaller the tubing diameter, the larger the internal surface. This large volume of surface area gives bacteria and biofilm plenty of room to establish themselves.

Bacteria and pathogens are opportunists, and they will exploit the nature of dental tubing to their advantage. According to The Organization for Safety, Asepsis, and Prevention (OSAP), “This proportional increase in the amount of potential biofilm relative to a given water volume is one of the major factors influencing dental water quality in unrelated systems.1” Once biofilm are established, they can be difficult to eliminate. If left unchecked,

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biofilm will exhibit a resistance to common disinfectants, making the situation even more problematic7. Consider other growth factors unique to dental systems, such as water temperature, flow rates and frequent stretches of stagnation. The culmination of all these factors allows the bacterial load in the waterline to exceed the CDC and EPA drinking water standard of 500 CFU/ml.

So why is this a problem? According to OSAP, “As many as nine potentially pathogenic organisms associated with opportunistic wound and respiratory infections have been isolated from dental unit water systems.”1 When coolant and irrigant water is used in conjunction with a high speed dental handpiece, the contaminated water is aerosolized along with the bacteria. Now you really have a problem! If patients or the dental team inhales these water droplets, they’ve now been exposed to whatever was growing in the dental unit. There’s also the good old fashioned way of exposed tissue (or dental pulp) being infected when the site is irrigated with contaminated water. Either way, serious infections can be the result of a contaminated DUWL. So how can clinicians mitigate these risks? They can start with the water being supplied to the dental practice.

Most clinicians are not aware that municipal tap water could be contributing to their bacteria problems. Public water works

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SPONSORED BY STERISIL that deliver municipal tap water are prone to contamination and breaches in their own water quality standards. A common watermain break or leak presents an opportunity for pathogens to gain access to the public works. According to a 2012 report, these types of failures have been the cause of several bacterial and viral outbreaks of Salmonella, Campylobacter, Shigella, E. coli O157:H7, Cryptosporidium, Giardia and Norovirus2,3.

As of 1971, the Centers for Disease Control and Prevention (CDC), U.S. Environmental Protection Agency (EPA) and the Council of State and Territorial Epidemiologists (CSTE) have been tracking and quantifying these waterborne disease outbreaks in the United States. The most interesting insight from the data they provide is that over the 36-year period from 1971 to 2007, “a trend analysis found a statistically significant decrease in the annual proportion of reported deficiencies that were associated with the inadequate or interrupted treatment of water by public water systems4.” Conversely, the amount of outbreaks related to flaws in premise plumbing have increased in that time4.

Privately managed water treatment – or premises treatment – are technically outside the jurisdiction of a water utility.

The liability falls to building managers to implement a strategy for maintaining waterlines after the meter. According to the American Society for Microbiology, “Health care settings, such as hospitals and nursing homes, were the second most common outbreak location in community systems, highlighting the need for continued vigilance to ensure provision of safe water to locations that serve populations that are more vulnerable, such as hospitalized patients or nursing home residents with preexisting medical conditions.”4 For dental professionals in large healthcare facilities, it is certainly worth speaking with building managers about the plans for water treatment within the building. Systems of water quality monitoring and intermittent testing should be in place where the consequences could be serious.

after nine pediatric patients were hospitalized in the same facility. The CDC reported that the Georgia Department of Public Health (GDPH) initiated an investigation, which revealed that all of the patients (between the ages of 3-11) had previously undergone a pulpotomy procedure at the same dental clinic. Upon visiting the clinic to evaluate their infection control policies, GDPH staff indicated the practice used tap water for irrigation during the pulpotomies. The report also indicated the practice lacked any level of monitoring or disinfection efforts as directed by the chair manufacturer. The report concluded that all seven operatories had bacterial counts above the 500 colony forming unit (CFU) drinking water standard and M. abscessus was identified in all samples5.

If a dentist intends to use their municipal water for dental water – and, yes, there is a difference – it would be advisable to have some level of water quality analysis before selecting the product.

Variations in tap water quality are virtually infinite and, therefore, the dental practice should not rely on tap water for consistent disinfection results. The presence of municipal disinfectants and additives, such as chlorine and fluoride, complicates things further if the practice is trying to manage the chemistry, as it should to get the best results. By failing to do so, the dental practice has a concoction of different chemicals and additives mixing in the waterline. The byproduct of these unwanted mixtures is called precipitates, and their presence indicates the diminished effectiveness of whatever exists in the water to control microbes.

So what is the solution? To attain maximum chemical control, distilled quality water is best. That said, distilled water from a distiller is not always optimal for dental water. The nature of distillation requires that one heat the water to remove impurities.

This hot distillate is now primed for recolonization by bacteria.

Without immediate waterline treatment, this water will most assuredly be contaminated. Without the presence of a continuously present residual disinfectant, that water will most assuredly be a breeding ground for bacteria. Distillers themselves are often the source of contamination for many offices, as once the storage tank is contaminated the water is then distributed along with the bacteria to the entire office.

Manufacturers spend unmentionable amounts of money on development, EPA registration and validation for their products. The EPA label will run down all the necessary steps needed to get the advertised disinfection level.

Clinicians should not go rogue on these protocols!

Maximum chemical control In 2015, reports began to circulate that a cluster of Mycobacterium abscessus infections had been identified in Atlanta, Ga.

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The best strategy is a point-of-use purification system using deionization to remove all the impurities without heating the water. Ultraviolet disinfection can then be employed to drastically lower the existing bacterial load with proven effectiveness8.

The water would then receive a low concentration of a residual disinfectant. The final product is water that is neutral in pH, contains less than 10 ppm total dissolved solids, is disinfected and contains some variety of residual disinfectant.

Now the water is pure and bacteria free. So the treatment process is complete, right? Not even close! We haven’t gotten to the most important part – the dental water use protocols.

Without sound operating protocols, everything the dental practice has done up to this point would be for not.

Dental water use protocols Manufacturers spend unmentionable amounts of money on development, EPA registration and validation for their products. The EPA label will run down all the necessary steps needed to get the advertised disinfection level. Clinicians should not go rogue on these protocols! When it comes to quality assurance (QA), OSAP recommends procedures that flush out user error6. Let’s face it, people can make mistakes. Minor investments like TDS hand meters will allow some level of protocol QA. For example, when using distilled water in their bottles, clinicians should randomly check the TDS count and ensure the result is less than 20 ppm.

If it’s greater than 20 ppm, they can assume the water in that bottle is not distilled and that someone has botched the procedure for refilling it. Protocol consistency and quality failsafes are fundamental to getting all of this waterline stuff done right.

Consistency leaves nothing to chance. This is also important, as manufactures design their products to work within certain parameters. We’ve already discussed the variability in water chemistry across the spectrum. Deviations in protocol, like the example above, could mean the dental practice is no longer operating within those parameters and, subsequently, it may have contributed to contamination in the unit.

So what is compliance under the current standards? The acceptable standard set by the CDC and the ADA for bacterial

content in a dental unit is ≤500 CFU/ml. Compliance is not a state of mind; it’s a state of being. The notion that purchasing a product and following the instructions puts one in compliance is just wishful thinking. A complete and thorough waterline assessment performed by a 3rd party lab specializing in dental water microbes will provide all the information necessary. TDS, pH, and HPC counts in CFU/ml are the general markers of waterline cleanliness. These test results can be used to make adjustments to the waterline protocol or confirm that clinician’s efforts are having the desired effect. It can be something as Most clinicians simple as a change in the daily are not aware that use or as extensive as a municipal tap water staff complete overhaul of the regicould be contributing men at large. to their bacteria Contaminated dental unit waterlines are a real threat to problems. Public patient and staff safety. Their water works that design, the nature of dental deliver municipal tap procedures and the conditions water are prone to within the dental operatory contamination and prime them for bacterial colonization. We know the problem breaches in can be exacerbated by using their own water municipal water instead of quality standards. purified or distilled water, and the case data proves this point.

The most important takeaway from this piece is that whatever clinicians do, they should be consistent. They should read manufacturers guidelines and follow them, as there may be something they’ve been missing.

When they feel like everything is going well, they shouldn’t assume it is. Rather, they should order a test and know for sure.

If clinicians miss the mark, they should reevaluate their plan, retrain their staff and retest to confirm the change. Attaining the <500 CFU/ml standard in dental effluent water is the culmination of forethought, execution, consistency and vigilance.

No excuses!

Bibliography 1. B erdnash, Helene, et al. “Dental Unit Waterlines: Check Your Dental Unit Water IQ.” Dental Unit Waterlines - OSAP, www.osap.org/page/Issues_DUWL_7XXXX/Dental-Unit-Waterlines.htm.

2. I ngerson-Mahar, M.; Reid, A. Microbes in Pipes: The Microbiology of the Water Distribution System A Report on an American Academy of Microbiology Colloquium; ASM Academy: Boulder, CO, USA, 2012; p. 26.

3. R amírez-Castillo, Flor, et al. “Waterborne Pathogens: Detection Methods and Challenges.” Pathogens, vol. 4, no. 2, 2015, pp. 307–334., doi:10.3390/pathogens4020307.

4. C raun, Gunther F., et al. “Welcome to CAB Direct.” CLINICAL MICROBIOLOGY REVIEWS, vol. 23, no. 3, July 2010, pp. 507–528., www.cabdirect.org/cabdirect/abstract/20103246391.

5. P eralta, Gianna, et al. “Morbidity and Mortality Weekly Report (MMWR).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 25 Aug. 2017, www.cdc.gov/mmwr/volumes/65/wr/mm6513a5.htm.OSAP - Dental Unit Waterlines 6. A. Bridier, R. Briandet, V. Thomas & F. Dubois-Brissonnet. “Resistance of bacterial biofilms to disinfectants: a review” Biofouling Vol. 27 , Iss. 9,2011 7. C hevrefils, Gabriel, et al. UV Dose Required to Achieve Incremental Log Inactivation of Bacteria, Protozoa and Viruses. UV Dose Required to Achieve Incremental Log Inactivation of Bacteria, Protozoa and Viruses, Trojan Technologies Inc., 2006.

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DENTAL UNIT WATER

Safe dental water… …should be a priority at every practice.

The quality of

dental unit water has been a topic of discussion and research for many years. Indeed, outbreaks of infection linked to the dental waterline can be a health risk for patients and a liability risk for dental practices.

It’s the ethical and professional responsibility of dental practitioners to provide safe dental water to their patients, and manufacturers, such as Hu-Friedy, make it a priority to keep them informed and provide optimal solutions for helping clean and maintain water used at their dental practice. Hu-Friedy offers a number of educational resources, including live continuing education courses, articles, on-demand webinars, step-bystep guides and customer service support. (To view their online resources, please visit: http://www.hu-friedy.com/education/ infection-prevention-resources.)

According to the 2003 CDC Guidelines, “Dental unit water that remains untreated or unfiltered is unlikely to meet drinking water standards (303-309).” Dentists have several options for ensuring safe water standards at their dental practice, such as the following: • Filtration devices with in-line filters to remove bacteria before water enters the handpiece or other devices attached to the waterline.

• Independent reservoirs with chemical germicides or cleaners to remove microbial accumulations and prevent attachment of microorganisms, such as Hu-Friedy’s Team Vista Dental Unit Waterline Cleaner.

• Devices or cartridges that provide a slow release of chemicals.

Common misconceptions

The CDC offers several steps to help dentists ensure the safety of their dental water: • Use water that meets EPA regulatory standards for drinking water.

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

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

• 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.

• Consult with manufacturer on the need for periodic maintenance of anti-retraction mechanisms.

Contrary to what some dental professionals may realize, ALL dental waterlines – regardless of how new or old they are – must be

Editor’s note: Sponsored by Hu-Friedy.

Whichever method is chosen, it is critical to monitor waterlines on a periodic basis to ensure their efforts and product are working.

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cleaned and maintained. According to the CDC, “Research has demonstrated that microbial counts can reach <200,000 colony-forming units (CFU)/mL within 5 days after installation of new dental unit waterlines (305), and levels of microbial contamination <106 CFU/mL of dental unit water have been documented (309,338). These counts can occur because dental unit waterline factors (e.g., system design, flow rates, and materials) promote both bacterial growth and development of biofilm.”

Additionally, it’s essential for dental offices to understand that ensuring their source water meets CDC standards is a twostep process that involves both cleaning and maintenance. To help prevent waterborne organisms from attaching, colonizing and proliferating on the inner surfaces of water tubing, a complete dental unit waterline system should be used. Complete systems to control the quality of water delivered to patients include both periodic cleaning AND routine maintenance.

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Editor’s Note: Technology is becoming an integral part of the day-to-day business of sales reps. In this department, First Impressions will profile the latest developments in software and gadgets that reps can use for work and play.

Technology News It’s about being everywhere It was Google versus Alexa at the Consumer Electronics Show in Las Vegas, reports Wired. “Right now, by all accounts, Amazon’s Alexa is winning the virtual assistant battle,” its editors report. “It was in hundreds of third-party devices at last year’s CES, and though Amazon doesn’t release specific sales figures beyond the ‘tens of millions’ statement from CEO Jeff Bezos, Echo devices appear to outsell Google Homes by a wide margin. Not only that, Amazon’s working with a growing list of partners to embed Alexa in other devices as well. Google needs to catch up fast if it wants to compete. Its Google Home products – the Home, Mini and Max – are solid enough, but they’re just the beginning of the ecosystem. The winning virtual assistant will be the one that

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first achieves ubiquity. It’s about doing everything, and being everywhere. Once people pick an assistant and start using it in their lives, they’re not likely to switch. The stakes are high, and immediate.”

TV lexicon New TVs are coming, with an alphabet soup of features designed to get you to spend more money, reports the Associated Press. Some terms to keep in mind: • HD, 4K, 8K: Lots and lots of pixels, for some sharp viewing.

• OLED: Stands for Organic, light-emitting diodes. Selfilluminating pixels, so that images can have truly black areas, not just really dark ones (which, we guess, is a good thing?).

• MicroLED: Micro light-emitting diodes, said to offer the same benefits of OLED without the potential “burn-in.”

• HDR and HDR10: High dynamic range using 10 “bits” to represent color gradations. Said to include the brightest bright parts and the darkest dark parts without either dominating the image.

• Dolby Vision and HDR10+: Sixty-nine billion color variations.

• Quantum dots, QLED, QDEF: Quantum dots are tiny particles that emit sharp colors based on their particular size, leading to very accurate colors.

Toilet talk Chicago Tribune columnist Rex Huppke says he doesn’t want to have anything to do with talking toilets, such as the Kohler Numi toilet, displayed at the Consumer Electronics Show in Las Vegas. Conversations could lead to hard feelings. Example: • Toilet: “Hello Rex, welcome to the bathroom. What can I do for you?”

• Huppke: “Raise the seat, please.”

• Toilet: “Sure! How is your day go … HEY! WHAT ARE YOU DOING? OH GOD, THIS IS TERRIBLE!!!”

Love at first algorithm Science can’t beat the human heart when it comes to love, according to the Advertising Standards Authority in London. A billboard ad on a London Underground platform for the online dating service, eHarmony, seen on July 4, 2017, featured the headline claim “Step aside, fate. It’s time science had a go at love,” according to the ASA. Further text stated “Imagine being able to stack the odds of finding lasting love entirely in your favour. eHarmony’s scientifically proven matching system decodes the mystery of compatibility and chemistry so you don’t have to. Why leave the most important search of your life to chance? Try something different today. Join eharmony.co.uk”. A complaint was lodged, claiming that it is not possible to hold scientific proof about a dating system.

In its assessment, the ASA wrote, “The ASA considered that consumers were likely to appreciate that the advertised dating website would not be able to guarantee that they would be able to find lasting love. However, we considered that consumers would interpret the claim ‘scientifically proven matching system’ to mean that scientific studies had demonstrated that the website offered users a significantly greater chance of finding lasting love than what could be achieved if they didn’t use the service.”

The ruling? The ad must not appear again in its current form.

“We told eHarmony to remove the claim ‘scientifically proven matching system’ and not to use similar claims with the same

meaning, unless they had adequate evidence that their website offered users a significantly greater chance of finding lasting love than what could be achieved if they didn’t use the service.”

Poolside Wi-Fi Extend your Wi-Fi coverage outdoors up to an additional 2,500 square feet with the Orbi™ Outdoor Satellite from NETGEAR. Users connect the Orbi router to an Internet modem or service provider gateway, and place the Orbi satellite somewhere central to the area of intended Wi-Fi coverage.

Depending upon the Orbi System installed, the Wi-Fi coverage area can range from 3,500 square feet up to 5,000 feet around your property. By adding an Orbi Outdoor Satellite to an existing Orbi WiFi System, the range of the WiFi mesh coverage zone can be expanded to another 2,500 square feet extending to the farthest perimeter of your property for Wi-Fi at the pool, guest house, garage and the grill. Designed to withstand rough outdoor weather conditions including sub-zero temperatures, Orbi Outdoor Satellite has an international standard IP56 rating for dust and waterresistance, according to the manufacturer. Cost: $330.

By adding an Orbi Outdoor Satellite to an existing Orbi WiFi System, the range of the WiFi mesh coverage zone can be expanded to another 2,500 square feet extending to the farthest perimeter of your property for Wi-Fi at the pool, guest house, garage and the grill.

Whip it good.

With its 700-watt motor, Braun’s latest immersion blender “blows through foodstuffs that lesser sticks can’t crack – ice cubes, raw potatoes, or even a peeled avocado with pit (if you crave those bitter tannins),” reports Wired. The device sells for $150. “Below the soft grip is a compression zone – push down and the spinning slicer moves closer to the bottom of your vessel, ensuring every last bit of basil and garlic becomes pesto,” reports the magazine. “Squeezing the trigger speeds up the blades and takes your mix from chunky to smooth. No apron? No problem. Those funkily shaped feet are designed to keep splatter to a minimum.”

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HEALTHY REPS

Health news and notes A spoonful of trehalose Over the past 15 years or so, some makers of ice cream and other processed foods – from pasta to ground beef products – have changed their recipes to swap out some of the table sugar (sucrose) with a sweetening/texturizing ingredient called trehalose, which depresses the freezing point of food. Both sucrose and trehalose are “disaccharides.” Though they have different chemical linkages, both get broken down into glucose in the body. A study in the journal Nature indicates that trehalose-laden food may have helped fuel the recent epidemic spread of Clostridium difficile (C. diff.), which is a microbe that can cause lifethreatening gastrointestinal distress, especially in older patients getting antibiotics and antacid medicines. In laboratory experiments, a National Institutes of Health-funded team found that the two strains of C. diff. most likely to make people sick possess

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an unusual ability to thrive on trehalose, even at very low levels.

What’s more, a diet containing trehalose significantly increased the severity of symptoms in a mouse model of C. diff. infection.

Keep it real The LinkSquare is a magic marker-sized scanner that can tell if meat is rotten, whether alcohol is fake, or prescription pills are what they’re supposed to be, reports USA Today in a report about the Consumer Electronics Show (CES) in Las Vegas in January.

It can even tell if the money in your pocket is counterfeit. It pairs with an app on your phone. Price is $300.

Protect your skin Another gadget worth noting at the Consumer Electronics Show was L’Oreal’s UV Sense, a wearable small enough to fit

on your fingertip, reports USA Today. The dot tells you UV, pollen, humidity, temperature and air quality levels. It pairs with an app on your smartphone and can give you reminders to put on more sunscreen (L’Oreal is suggested!) or stay out of the sun altogether. Costs about $40.

Dieting? Watch the clock Don’t focus so much on how much you eat, but rather, on when you eat. That’s the concept behind time-restricted feeding, or TRF, a strategy increasingly being studied by researchers as a tool for weight loss, diabetes prevention and even longevity, according to Sumathi Reddy of the Wall Street Journal.

In TRF, you can eat whatever you want and as much as you want – just not whenever you want, she writes. (That doesn’t mean you can stuff yourself with goodies; rather, eat as you normally would.) Daily food intake should be limited to a 12-hour window, and ideally cut down to eight to 10 hours.

Despite a lack of dietary restrictions, most people following TRF end up consuming fewer calories and lose weight.

Preliminary evidence also shows other health benefits of fasting for 12 hours or more, including lower blood pressure and improved glucose levels, and physiological changes linked to slowing the aging process.

DASH ranked best diet For the eighth consecutive year, U.S. News and World Report ranked the National Institutes of Health-developed DASH Diet “best overall” diet among nearly 40 it reviewed. The announcement came as new research suggests that combining DASH, or Dietary Approaches to Stop Hypertension, with a low-sodium diet has the potential to lower blood pressure as well as or better than many anti-hypertension medications. DASH is a healthy eating plan that supports long-term lifestyle changes, according to NIH. It is low in

saturated fat, trans fat, and cholesterol. It emphasizes fruits, vegetables, and low-fat dairy foods, and includes whole grains, poultry, fish, lean meats, beans, and nuts. It is rich in potassium, calcium, and magnesium, as well as protein and fiber.

However, it calls for a reduction in high fat red meat, sweets, and sugary beverages. To read more about DASH, go to https://www.nhlbi.nih.gov/health-topics/dash-eating-plan.

DASH is a healthy eating plan that supports long-term lifestyle changes, according to NIH. It is low in saturated fat, trans fat, and cholesterol.

It emphasizes fruits, vegetables, and lowfat dairy foods, and includes whole grains, poultry, fish, lean meats, beans, and nuts.

Even the frail can benefit Physicians should prescribe physical activity to all older patients, regardless of frailty status, according to researchers at the USDA Human Nutrition Research Center on Aging at Tufts University and Geneva University Hospitals. Although a structured, moderate-intensity physical activity program was not associated with a reduced risk for frailty over two years among sedentary older adults, it did reduce major mobility disability in both frail and nonfrail patients. Study participants were randomly assigned to a program consisting of aerobic, resistance, and flexibility activities or a health education program consisting of workshops and stretching exercise. Findings from a secondary analysis of the LIFE (Lifestyle Interventions and Independence for Elders) trial are published in Annals of Internal Medicine.

Bummer Vitamin D and calcium supplements do not seem to be warranted to prevent bone breaks or hip fractures in adults over the age of 50, according to a study published in the Journal of the American Medical Association on Dec. 26. Such supplements had no clear benefit regardless of dose, the gender of the patient, history of fractures or the amount of calcium in the diet, reports the Washington Post. The analysis, conducted by Jia-Guo Zhao of Tianjin Hospital in China, was focused on older adults who live in the general community and did not include those in nursing homes, hospitals and other facilities.

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