Complete Guide to Treating Dental Unit Waterlines

As you may already know or have experienced, bacteria don’t quit. In everyday use of dental equipment, the minute you put your cavitron down, bacteria are working to multiply and adhere to the sides of the tiny tubes they reside in. One essential element of combatting bacterial growth is to continuously treat your waterlines. 

In this article we will discuss the following:

• Why is continuous waterline treatment necessary?
• What is an antimicrobial?
• What can I use for continuous treatment in dental unit waterlines?
• How much does each of the treatment options cost?
• Why not just shock every week?
• Can I use multiple treatment products together?
• Which dental unit waterline treatment option is right for my dental office?  

Why is continuous waterline treatment necessary? 

We often think of it this way, if waterline maintenance were compared to your own oral hygiene, treatment would be like daily brushing and flossing, whereas shocking (which we discuss in detail in our Complete Guide to Shocking Dental Unit Waterlines) is like going to a professional dental appointment. Both are essential to the long-term health of teeth (or waterlines), and both require upkeep.  

In the largest dental unit waterline study of over 22,000 waterline test results, we found that the most successful treatments in keeping waterlines compliant were a combination of shocking and treating. And, in Jean Barbeau’s study, Multiparametric Analysis of Waterline Contamination in Dental Units, he and his research team discovered that within just five days and in brand-new lines, bacteria counts can grow to 200,000 CFU/mL.  

Unfortunately, simply ignoring the reality of bacteria living in waterlines will lead to the exponentially larger challenge of removing established, mature biofilm than of keeping it from growing in the first place. 

What is an antimicrobial? 

Antimicrobials slow the spread of microorganisms which include bacteria, viruses, protozoans, and fungi such as mold and mildew. In the context of dental unit waterline maintenance, antimicrobials are used to keep bacteria from multiplying and forming a biofilm. Keep in mind that low-level antimicrobials, while important tools in infection prevention, are what we refer to as “maintainers.” They are essential in the waterline treatment process as they maintain and inhibit new bacterial growth, but they do not consistently destroy biofilm build-up (which is why you still need to shock your lines regularly).  

You might think of antimicrobials as the equivalent of “picking up” your home after a deep clean. Without grabbing the loose socks and strewn-about shoes, your house will reach the point of needing a deep clean again far faster than it would without picking up.  

What can I use for continuous treatment in dental unit waterlines? 

The types of treatment options used for a continuous flow of low-level antimicrobials in waterlines are: 

• Tablets 
• Cartridges/straws 
• Daily liquids 
• Central water systems 

You may already be using one of these treatment options (*insert slam poetry style snaps*) or you may be brand new to the dental waterline maintenance game (if so, welcome), either way, it’s important to understand what is available in the market and evaluate which is the right solution for your practice.

Tablets

What are daily maintenance tablets for dental unit waterlines? 

One of the most utilized waterline treatment methods is a daily maintenance tablet. Around 17 mil tablets are used by U.S dentists each year. These effervescent tablets are added to an independent reservoir (like a water bottle) each time it is refilled and slowly release their low-level antimicrobial.  

How do I use daily maintenance tablets for waterlines? 

Tablets, like BluTab®, are popular because of their ease of use and effectiveness. Before starting treatment, be sure to consult the product IFU as there may be variations to these steps. However, tablets are generally added to a water bottle (or water jug if you mix the solution in bulk) every time it is refilled. Tablets are easy to use, even for individuals who are new to your dental office.  

How long do daily maintenance tablets last? 

Tablets have active ingredients that remain effective for 14-28 days, should your water last that long. 

Pros of Daily Treatment Tablets for Dental Waterline Maintenance: 

• Easy to use 
• No installation required 
• Generally, cost-effective 
• Low maintenance 

Cons of Daily Treatment Tablets for Dental Waterline Maintenance: 

• Must be added with each water bottle refill 
• Can be less cost-effective if the practice uses a high volume of water daily

Cartridges/Straws

What are water treatment cartridges and straws? 

In-line cartridges or straws, like BluTube®, release a low-level antimicrobial into the water as it passes through the cartridge. Straws are designed to attach to the uptake tube and sit inside the bottle, allowing water to continuously filter through it. 

How much maintenance is required for waterline treatment cartridges and straws?      

The primary benefit of cartridges or straws is that they require minimal daily management once installed (follow the detailed instructions provided in your IFU for how to install your unit). It is recommended that you empty the water from the water bottle each day and wipe down the straw.  

However, straws are not a “set it and forget it” solution. Without regularly shocking your lines, the use of any straw, cartridge, or other low-level antimicrobials will be overpowered by aggressive bacteria which will begin to colonize and form biofilm.  

How long do cartridges and straws last? 

The most popular straw claims to last for a year or 240 liters of water, whichever comes first. But, we have seen cartridges lose strength in fighting biofilm buildup around seven-nine months after installation. This is why we offer BluTube® with two cartridges to ensure that at the critical “6-month” window, you have a fresh straw to help power through for the entire year. 

Pros of Cartridges and Straws for Dental Waterline Maintenance: 

• Easy to use once installed 
• Minimal upkeep 
• Cost-effective when using high volumes of water daily 

Cons of Cartridges and Straws for Dental Waterline Maintenance: 

• Requires initial installation 
• Should be wiped down daily

Daily Liquids

What are water treatment daily liquids? 

Daily liquids are just as they sound, they are a liquid low-level antimicrobial that is added to an independent water bottle each time it is refilled.  

How much maintenance is required for waterline treatment daily liquids? 

Distinct from shocking liquid, waterline daily treatment liquids are the least used option in dentistry though they can be effective when used as directed and the upkeep is like that of tablets. The user should be sure to follow IFUs to add the liquid to water bottles when refilled.  

How long do daily liquids last? 

This treatment option lasts however long a water bottle does in your practice. Once a bottle is empty, the liquids must be added once again. 

Pros of Daily Liquids Dental Waterline Maintenance: 

• Easy to use 
• No installation required 
• Generally, cost-effective 
• Low maintenance 

Cons of Daily Liquids Dental Waterline Maintenance: 

• Must be measured and added with each water bottle refill 
• Can be less cost-effective if the practice uses a high volume of water daily 

Central Water Systems

What is a central water filtration system? 

Central water filtration systems are connected to the municipal water source and then connect directly to dental operatories. These systems are generally intended to remove total dissolved solids (TDS) such as minerals, salts, and chlorine from the water before it enters waterlines.

Often, central systems are sold as a silver bullet for managing water quality throughout the practice and, once the equipment is installed, no other maintenance is required to maintain safe water. But, based on the data from Dr. Mollinari and Nancy Dewhurst’s 2018 study, water samples from dental lines that were maintained solely by centralized filtration systems results were compliant (< 500 CFU/ml) at about 58% of the time.  

However, central systems are getting better at addressing the needs of waterline maintenance. Newer models sometimes contain a treatment filter or antimicrobial component. Keeping up with your central system to ensure effectiveness is often far more time-consuming and costly than any other option we’ve discussed so far. 

How much maintenance is required for central water systems? 

Central water systems have more variables than other treatment methods but, generally, it is recommended that filters are changed out at least every six months. In some cases, the dental office staff cannot maintain many of the larger filtration systems, so the sanitization must be performed by a technician. 

What is the lifetime of a central water system? 

The lifetime of these systems, understandably, will vary depending on the unit. Make sure to refer to the warranty and maintenance guides to ensure your team follows the manufacturer’s recommendations to keep your system in pristine condition. 

Pros of Central Water Filtration Systems for Dental Waterline Maintenance: 

• Some models have a shock filter and/or an antimicrobial filter 
• Excellent at removing total dissolved solids 
• Has multiple functions outside of just waterline maintenance 

Cons of Central Water Filtration Systems for Dental Waterline Maintenance: 

• The most expensive treatment option 
• Expensive and time-consuming to maintain 
• Usually needs a third-party to clean and manage 
• Some models have more focus on the removal of TDS than waterline maintenance 
• Not as user-friendly as other treatment options 

How much does each of the treatment options cost? 

Tablets are thought to be one of the most cost-effective waterline treatment options. However, the cost-effectiveness depends on how much water is used in the dental office. If you use less than a bottle of water per day at each operatory, tablets will be the best option, but if you refill water bottles more often (or use greater than 200 L/year), you may want to consider other treatment options like cartridges/straws.  

Central systems are certainly the most expensive treatment option, ranging from several hundred to tens of thousands of dollars for the initial equipment not including the cost of filters (starting around $1,500/filter in a multi-filter system) or professional maintenance. If you do decide to purchase a central filter system, make sure you know if there is any waterline treatment functionality built in. If not, you will still need to use a daily treatment product and shock regularly. 

Why not just shock every week? 

While they are certainly effective in destroying bacteria and breaking down biofilm, we generally do not recommend relying on a weekly shock for the following reasons: 

1. Time commitment – Because shocking solutions should never come in contact with patients and cannot be used with autoclavable pieces, you will need to complete the process when the operatory is shut down and when you can remove all autoclavable pieces. This requires far more effort, time, and planning. With a continuous treatment, shocking can be performed quarterly or even less depending on test results.
2. Human error – If shocking is missed for one week (or even a few days), bacteria will gladly take advantage of the opening. Because there is nothing to stop the exponential growth in the waterlines, these bacteria are likely to form biofilm.
3. Chemical makeup – shocking solutions are truly meant to be used as a “shock” product. When used quarterly, the solution is safe, but when used weekly, the strength of the chemical could damage your equipment.
4. Cost – Because some shocking solutions are quite expensive, running the entire shocking drill every week can become expensive very quickly. 

 Ultimately, we recommend you follow the three-step proven protocol which directs that you shock quarterly, for the most effective process and most consistent results. 

Can I use multiple treatment products together? 

Again, too much of a good thing is not a great thing in this case. Because each treatment product is designed to work independently, they don’t play well with others. We’ve seen that attempting to use multiple daily treatment products can lead to bubbling or strange-tasting water, which will make for a less-than-desirable patient experience.  

Keep it simple. Use a single treatment product and, if you choose to switch products—whether that be brands or types of treatment—be sure to shock your lines before starting something new. 

Which dental unit waterline treatment option is right for my dental office? 

The perfect waterline treatment protocol can vary from practice to practice. So, we recommend that when considering a treatment product, you answer these questions:

How easy to use does the treatment need to be for the staff who will manage it?

If you need an option that requires no training or installation, tablets or liquids may be the right option for you. If your team is able to follow the instructions for the one-time installation of straws or cartridges, these are even easier to manage on a day-to-day basis. Central filtering systems may not require maintenance from your team, but they will likely need regular tune-ups from a professional. 

Is convenience or cost important factors to your practice being waterline compliant? 

If your office wants to keep costs low, you may consider tablets, daily liquids, or straws and cartridges. The cost for each of these will vary depending on how much water the practice uses on average.  

What volume of water does your practice go through each day? 

You may not have an exact number in mind, but if you go through more than a bottle of water at each operatory per day, cartridges or straws may be the most cost-effective and lowest maintenance option available. 

If you’ve answered these questions and still aren’t sure which path is right for your team, feel free to chat with one of our safe water experts to build a custom protocol for your practice. 

What comes next? 

Remember that treating your waterlines with a low-level antimicrobial is essential to maintaining compliant and safe water, but it is just one of the three steps in the proven protocol.

After the effort you’ve taken to treat your lines, it’s time to test your water and verify the effectiveness of your hard work. If it’s your first time testing, don’t worry, we’ve got you covered. Here is our Complete Guide to Testing Dental Unit Waterlines.