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MEANING IS PERCEPTION
MEANING IS PERCEPTION If dentistry doesn't want to lose the positive public image it has created regarding the safety of dental visits, it can't wait five years for pure water.
Os a frequent flyer who, until recently, was secure in the belief that the risks of flying were minimal, I found a report in a leading travel magazine very disturbing. The article suggested that breathing the air in an airplane cabin can lead to serious disease. Tuberculosis, it seems, was spread from a crew member with active TB to fellow crew members and, so the author inferred, perhaps to some flyers on the plane. I am now a concerned frequent flyer. Every unshielded passenger cough and sneeze makes me run for cover. I now "see" infectious droplets everywhere and can almost "feel" a sore throat coming on. Scientific research, the airlines maintain, indicates that the concentration of microorganisms in cabin air is less than that in many city locations. That finding does little to reduce my apprehension. I'm not going to stop flying, but I want evidence that the air surrounding me in my airplane is free of pathogenic organisms. A similar scenario involving dental patients might be occurring in certain areas of the United States. Local media exposes of unsafe, "disease-causing" water coming from some dental unit water lines, or DUWLs, may be alarming some patients. As in the airline example, the information probably won't stop patients from making dental visits, but they would feel much better if they knew the
E D
LAWRENCE H. MESKIN, D.D.S. EDITOR
154 JADA, Vol. 127, February 1996
I
TGO
R
HAL
water in the office wasn't contaminated. Until that assurance is offered, their dental visits will not be as comfortable. To address this issue, the ADA, through its Council on Scientific Affairs, has just issued a policy statement calling on all interested parties to work toward developing dental equipment by the year 2000 that can deliver water that meets present standards used in hemodialysis units. While I applaud this recommendation, I believe the time line should and can be shortened. Let me explain. The dental profession has been successful in assuring the public that a dental visit is safe. To lessen or eliminate the spread of infection to patients, barrier techniques are mandated for each office.
-~RVIEISDentists sterilize everything. The office operatory equipment is scrubbed and wrapped. Dental team members are appropriately gloved, masked and gowned. All dental patients should be impressed with the precautions taken to ensure a sterile environment. How then can dentists rationalize utilizing water, not even of potable standards, during the delivery of dental services? While no scientifically documented cases of serious illness in patients or dentists can be traced directly to DUWL contamination, there have been anecdotal reports of aerosolized infection in dentists. Recent calls for research to refute or substantiate these claims seem reasonable, especially in light of documented waterborne disease outbreaks in hospitals. Cases of Legionella infection have been linked to hospital water taps and shower heads. Of dental interest are a hospital case report that describes infection spread by gargling contaminated water before sputum collection, and a report of Pseudomonas infection after tap water was used to dilute antiseptic solution. If dentistry doesn't want to lose the positive public image it has created regarding the safety
OADA welcomes letters from readers on topics of current interest in dentistry. The Journal reserves the right to edit all communications and requires that all letters be typed, double-
of dental visits, it can't wait five years for pure water. I realize that the ADA has been proactive in dealing with this subject and has held several meetings with dental manufacturers and researchers to find solutions for this problem. However, much more needs to be accomplished. I suggest as a first step that the ADA's Division of Scientific Affairs, in conjunction with the ADA Health Foundation, make a series of grants available to researchers interested in developing mechanisms to reduce or eliminate biofilms in dental equipment. This action would be timely since dentistry's research leader, the National Institute of Dental Research, has not demonstrated a major interest in this subject. Ultimate resolution of the "bad" water issue will necessitate a two-pronged research effort. The highest priority should go to the development of technologies that will reduce or eliminate the effects of biofilm in DUWLs and concurrently address the issue of back flow. This latter subject is equally important, because failure to eliminate patient-to-patient contamination could compromise any new system. Second, research to ascertain whether there are any deleterious health
effects from contaminated DUWLs also needs to be conducted. Coupled with the research effort should be a continuing campaign to publicize any new technologic advances that might be readily incorporated into the practitioner's armamentarium. It appears that a device that employs chemical disinfection coupled with filtration may soon be available. At present, there are systems that feature autoclavable DUWLs. While the initial purchase cost may be high, this type of unit may prove to be cost effective when measured over time. Meanwhile, you can reduce the CFU (colony-forming units) count in your DUWLs by following the advice offered by the Council of Scientific Affairs and printed in this month's Journal (see the cover story on page 181). People too often assume that water that looks pure and doesn't taste or smell bad is OK. Dental patients are no exception. Any deviation from that perception could weaken the confidence the American people have in dentists and dentistry. The search to reduce present waterline contamination deserves the profession's highest priority. The year 2000 may be too late. .
spaced and signed. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.
the direct reimbursement dental benefit concept ("Letters," December 1995). Dr. Singer states, "DR plans have not all enjoyed rave reviews. Just check the statistic that relates to purchasers who re-sign with DR after the first contract expires." This innuendo that direct reimbursement doesn't work is
DIRECT REIMBURSEMENT
I am compelled to respond to comments made by Dr. Singer regarding the effectiveness of
156 JADA, Vol. 127, February 1996
mm.
Os a frequent flyer who, until recently, was secure in the belief that the risks of flying were minimal, I found a report in a leading travel magazine very disturbing. The article suggested that breathing the air in an airplane cabin can lead to serious disease. Tuberculosis, it seems, was spread from a crew member with active TB to fellow crew members and, so the author inferred, perhaps to some flyers on the plane. I am now a concerned frequent flyer. Every unshielded passenger cough and sneeze makes me run for cover. I now "see" infectious droplets everywhere and can almost "feel" a sore throat coming on. Scientific research, the airlines maintain, indicates that the concentration of microorganisms in cabin air is less than that in many city locations. That finding does little to reduce my apprehension. I'm not going to stop flying, but I want evidence that the air surrounding me in my airplane is free of pathogenic organisms. A similar scenario involving dental patients might be occurring in certain areas of the United States. Local media exposes of unsafe, "disease-causing" water coming from some dental unit water lines, or DUWLs, may be alarming some patients. As in the airline example, the information probably won't stop patients from making dental visits, but they would feel much better if they knew the
E D
LAWRENCE H. MESKIN, D.D.S. EDITOR
154 JADA, Vol. 127, February 1996
I
TGO
R
HAL
water in the office wasn't contaminated. Until that assurance is offered, their dental visits will not be as comfortable. To address this issue, the ADA, through its Council on Scientific Affairs, has just issued a policy statement calling on all interested parties to work toward developing dental equipment by the year 2000 that can deliver water that meets present standards used in hemodialysis units. While I applaud this recommendation, I believe the time line should and can be shortened. Let me explain. The dental profession has been successful in assuring the public that a dental visit is safe. To lessen or eliminate the spread of infection to patients, barrier techniques are mandated for each office.
-~RVIEISDentists sterilize everything. The office operatory equipment is scrubbed and wrapped. Dental team members are appropriately gloved, masked and gowned. All dental patients should be impressed with the precautions taken to ensure a sterile environment. How then can dentists rationalize utilizing water, not even of potable standards, during the delivery of dental services? While no scientifically documented cases of serious illness in patients or dentists can be traced directly to DUWL contamination, there have been anecdotal reports of aerosolized infection in dentists. Recent calls for research to refute or substantiate these claims seem reasonable, especially in light of documented waterborne disease outbreaks in hospitals. Cases of Legionella infection have been linked to hospital water taps and shower heads. Of dental interest are a hospital case report that describes infection spread by gargling contaminated water before sputum collection, and a report of Pseudomonas infection after tap water was used to dilute antiseptic solution. If dentistry doesn't want to lose the positive public image it has created regarding the safety
OADA welcomes letters from readers on topics of current interest in dentistry. The Journal reserves the right to edit all communications and requires that all letters be typed, double-
of dental visits, it can't wait five years for pure water. I realize that the ADA has been proactive in dealing with this subject and has held several meetings with dental manufacturers and researchers to find solutions for this problem. However, much more needs to be accomplished. I suggest as a first step that the ADA's Division of Scientific Affairs, in conjunction with the ADA Health Foundation, make a series of grants available to researchers interested in developing mechanisms to reduce or eliminate biofilms in dental equipment. This action would be timely since dentistry's research leader, the National Institute of Dental Research, has not demonstrated a major interest in this subject. Ultimate resolution of the "bad" water issue will necessitate a two-pronged research effort. The highest priority should go to the development of technologies that will reduce or eliminate the effects of biofilm in DUWLs and concurrently address the issue of back flow. This latter subject is equally important, because failure to eliminate patient-to-patient contamination could compromise any new system. Second, research to ascertain whether there are any deleterious health
effects from contaminated DUWLs also needs to be conducted. Coupled with the research effort should be a continuing campaign to publicize any new technologic advances that might be readily incorporated into the practitioner's armamentarium. It appears that a device that employs chemical disinfection coupled with filtration may soon be available. At present, there are systems that feature autoclavable DUWLs. While the initial purchase cost may be high, this type of unit may prove to be cost effective when measured over time. Meanwhile, you can reduce the CFU (colony-forming units) count in your DUWLs by following the advice offered by the Council of Scientific Affairs and printed in this month's Journal (see the cover story on page 181). People too often assume that water that looks pure and doesn't taste or smell bad is OK. Dental patients are no exception. Any deviation from that perception could weaken the confidence the American people have in dentists and dentistry. The search to reduce present waterline contamination deserves the profession's highest priority. The year 2000 may be too late. .
spaced and signed. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.
the direct reimbursement dental benefit concept ("Letters," December 1995). Dr. Singer states, "DR plans have not all enjoyed rave reviews. Just check the statistic that relates to purchasers who re-sign with DR after the first contract expires." This innuendo that direct reimbursement doesn't work is
DIRECT REIMBURSEMENT
I am compelled to respond to comments made by Dr. Singer regarding the effectiveness of
156 JADA, Vol. 127, February 1996
mm.