Waterline Infection Prevention in California – SB1491 & AB1277

Let’s face it. The legal jargon around dental unit waterline infection control is about as clear as…well, some of the failing water tests we see every day. So, we wanted to remove the murkiness and walk you through what California Dental Water Legislation SB 1491 and AB 1277 mean for your team and your dental practice. 

ProEdge has consulted with the Dental Board of California and the California Dental Association to make sure you know exactly what is required in CA’s dental infection prevention and control legislation.  

What do AB 1277 and SB 1491 mean for waterline infection prevention? 

First, Assembly Bill (AB) 1277 was established in May 2018 in response to the Dental Board of California’s vote to make emergency rule-making pursuant to California Business and Professions Code (BPC) Section 1601.6 after waterline contamination caused infection outbreaks in California and Georgia. It stated: 

Consistent with and in addition to the federal Centers for Disease Control and Prevention recommendations for water quality, the board shall amend the regulations on the minimum standards for infection control (Section 1005 of Title 16 of the California Code of Regulations) to require water or other methods used for irrigation to be sterile or contain recognized disinfecting or antibacterial properties when performing dental procedures that expose dental pulp. 

However, Senate Bill (SB) 1491 was introduced on February 21, 2018 to repeal and replace AB 1277. Thus, AB 1277 is void. 

SB 1491 clarified and narrowed the focus of the original bill. Signed by the Governor on September 22, 2018, and effective January 1, 2019, this bill states: “This bill makes using water, or other methods used for irrigation, that are not sterile or that do not contain recognized disinfecting or antibacterial properties when performing dental procedures on exposed dental pulp unprofessional conduct by a person licensed pursuant to the Dental Practice Act.” 

Left to decode the broad and succinct language, many dental practices, infection control experts, and manufacturers (including ProEdge) believed safe dental waterline treatment was the point of the bill, but this is not the case. 

SB 1491 does not govern dental water quality or dental unit waterline maintenance. 

Instead, SB 1491 regulates the use of oral irrigants, which are used for flushing out plaque, bacteria, and other toxins that become trapped in the small spaces between teeth and under the gumline, that are either sterile or are safe disinfectants for tissues like chlorhexidine, EDTA, BioPure MTAD and sodium hypochlorite (bleach) when dental pulp is exposed according to CDA Regulatory Compliance Analyst Teresa Pichay. 

So, what does SB 1491 mean for your dental office? 

In simple terms, a dentist must anticipate situations where pulp can be exposed, and anytime dental pulp is exposed, whether expected or unexpected, dentists must use sterile water or a disinfecting/antibacterial agent immediately to irrigate the exposed area of pulp.

Disinfecting agents that meet the SB 1491 Requirements: 

• Chlorhexidine 
• EDTA 
• BioPure MTAD 
• Sodium Hypochlorite (Bleach) 

Disinfecting agents that do not meet the SB 1491 Requirements: 

• Daily tablets (BluTab, Citrisil, ICX, Patterson, Z3, VistaTab) 
• Straws (BluTube, Sterisil, DentaPure, Hu-Friedy) 
• Daily Drops (TeamVista, MicroClear) 
• Central Systems & R/O Units 
• Shock Products (Liquid Ultra, Mint-A-Kleen, Monarch, VistaTab, Citrisil Shock) 

Waterline maintenance products like tablets and straws contain low-level antimicrobials. While being vital for maintaining clean waterlines, they are a different classification under the EPA and do not qualify as having “recognized disinfecting or antibacterial properties.” 

What’s the big deal with dental unit waterlines? 

In 2015 and 2016, two major infection outbreaks occurred in over 91 healthy patients from contaminated waterlines. The first happened in Georgia, and the second outbreak in Anaheim, California with 71 confirmed cases of mycobacterium abscessus. 

As the number of litigations increases, so does the attention from regulatory agencies. In 2018, the FDA announced their dental unit waterline guidelines for dental practices and dental device manufacturers. The Organization for Safety, Asepsis, and Prevention (OSAP) released one of the most comprehensive white papers on dental water quality to date in 2018 as well. 

Regulatory enforcement agencies like the DOH and OSHA are required to check waterline test results in accordance with the CDC Infection Prevention Checklist (Page 19). 

This has prompted many states (like California, Washington, and more) to outline specific waterline maintenance protocols within their dental board regulations. 

5 Tips to Being Compliant with Infection Prevention for Dental Unit Waterlines 

1. Use solutions that meet the standards in SB1491
   Use sterile water or water with recognized disinfecting or antibacterial properties whenever performing dental procedures on exposed dental pulp (See the list of products that meet this requirement above).
2. Shock your waterlines at least quarterly
   We’ve found in our study of over 22,000 waterline tests that the best protocol is to shock at least quarterly (lines with failing tests may need even more frequent shocking initially). No matter what treatment product you use, shocking is the most vital first step.
3. Use a continuous waterline treatment
   Use a daily or continuous waterline treatment like BluTab or BluTube. Again, for any continuous waterline treatment to be effective, ensure that you do this in tandem with shocking.
4. Test your waterlines quarterly
   Test your waterlines quarterly to ensure your protocol is effective. While many products can work, every product can fail. The only way to know if your protocol is effective is to test.
5. Get your practice a partner in waterline maintenance
   Get a partner. You didn’t get into dentistry to maintain waterlines, but we did. Any dental pro can consult with our water safety team to develop a proven protocol and learn best practices. Reach out today!