bakterier hos tandläkare

Vattnet i tandläkarstolen kan vara otjänligt, man har påvisat den mycket farliga legionellabakterien, i sköljvatten och vatten från borrar.

Problemet som är internationellt, uppmärksammades redan för många år sedan, men har trots detta inte lett till några verkliga åtgärder. För friska människor kanske det normalt inte är någon större fara, men för redan sjuka individer och personer med nersatt immunförsvar kan det vara mycket riskfyllt.

Undersökningar i USA visar att 90 procent av vattnet inte uppfyller kvalitetskraven för dricksvatten. Två tredjedelar innehåller bakterier från föregående patient (abcNews den 17 februari "Dirty Dental Water"). Redan i början av 80-talet uppmättes 1000 gånger så höga bakteriehalter på Odontologen i Göteborg som i vanligt kommunalt dricksvatten. Trots detta görs inga systematiska undersökningar av Smittskyddsinstitutet!

Tandvårdens trovärdighet

"Risken för patienter och tandläkare att smittas av legionellabakterien är obefintlig, säger Margareta Helander.
Det är svårt att bli kvitt bakterierna."
GP 23/02 "Smitta sprids hos tandläkaren"

Detta tvärsäkra uttalande liksom att den amerikanska tandläkarorganisationen ADA lika tvärsäkert avfärdar de av abcNews uppmärksammade riskerna som obefintliga, visar med skrämmande tydlighet att allmänheten inte kan lita på tandvårdens företrädare när de lika tvärsäkert avfärdar riskerna med amalgam.

abcNews "Dirty Dental Water"
GP 23/02 "Smitta sprids hos tandläkaren"

Nedan följer ett brev från hg-listan, en e-mail lista som alla intresserade kan prenumerera på.

To: Hg-listan
Subject: Dentists' Waterlines

Below is a recent news release from Wayne Obie:

Date: Sun, 20 Feb 2000 12:42:20 -0500
From: Wayne Obie <communications@talkinternational.com>
Subject: NEWS RELEASE - Fresh Water or Pond Scum
Content-Transfer-Encoding: 7bit
Content-Type: text/plain; charset=us-ascii
X-UIDL: d87531130bb1ca91e5858f31487bac41

For Immediate Release
February 20, 2000

Water In Dentists Office Compared to Pond Scum

A News feature aired on ABC's 20/20 News Magazine compared the water used in Dental Offices to Pond Scum.

The 20/20 investigation revealed that "almost 90% of the water samples tested did not meet federal drinking water standards, and two thirds of them contained oral bacteria from the saliva of previous partients."

20/20 also compared water from a number of dentists offices with water from PUBLIC toilets and found in nearly every case that the water from the toilets was cleaner than the water going into the patients mouths.

ADA spokeperson John Molinara stated "that there is no published eveidence of serious risk" (Where have you heard that before?) However, Dr. George Merijohn, a peridontist who has studied and written about the problem, explains that "the bacteria can potentially cause disease, especially in people with weakend immune systems. Any procedures like gum surgery, root canals and tooth extractions are riskier because they expose the gum line. It's an open wound" explains Merijohn, "and that's why in medical surgery they (doctors) would never think of using anything but sterile saline or sterile water".

In response to receiving this information a spokeperson for CFMR (Citizens for Mercury Relief) stated that "this is just one example of uninformed consent in the dental industry and one more very serious reason that the A.D.A. and the C.D.A. should be disbanded in favour of 'Citizens Review Boards'. It is obvious that these organizations do not and have never acted in the best interest of the patient."

CFMR, who is scheduled to release tomorrow for distributuion - Petitions calling for the eliomination of the A.D.A and the C.D.A,. and for the banning of mercury in Canada and the U.S , indicated that in light of this new information that they would be adding precautions to their already published "Checklist for Visiting Your Dentist" and be encouraging all dental patients to start collecting water samples from their dentists. Further information regarding this is expected to be published on CFMR's web site later this week.

Full transcript as well as live video and audio links to the 20/20 Program can be found on CFMR's Web Site at http://www.talkinternational.com

Wayne Obie
Media & Public Relations
CFMR (416) 410-6314
---------- end of forwarded message -------------

The ADA responded very quickly to this threat. A well-stocked armoury of reassuring statements is available at http://www.ada.org/prac/position/watertop.html since Feb 11, a week before the ABC's feature was aired. The problem has been touched on by the ADA years ago, but has it been solved at the practical level?

A MEDLINE search for "legionella" and "dental" yielded 30 hits. Below are the abstracts of six articles. Contamination of waterlines with the deadly Legionella has been known to the dental world for at least 15 years, and this is only one of the microorganisms involved.

J Dent Res 1985 Dec;64(12):1382-5
Prevalence of Legionella-specific IgG and IgM antibody in a dental clinic population.
Fotos PG, Westfall HN, Snyder IS, Miller RW, Mutchler BM

This study was undertaken to determine the frequency of Legionella infection in a dental clinic setting. Serum samples from 270 dental clinic personnel were evaluated using an enzyme-linked immunosorbent assay to detect Legionella-specific IgM and IgG antibodies. The pooled-species whole-cell-antigen preparation used in these assays was derived from six Legionella pneumophila strains and one strain each from Legionella bozemanii and Legionella micdadei. Significant levels of IgG and IgM antibodies were found in 20% and 16%, respectively, of the samples. This compares with 8% and 10%, respectively, for a randomly selected non-clinical group from the region (P less than 0.005). Samples from clinic personnel with significant IgG titers (greater than 1:128) were also evaluated for activity to each of the eight single-species antigens, with the following results: L. pneumophila, 45% (combined six strains); L. micdadei, 37%; and L. bozemanii, 18%. Comparing individuals' "years spent in the clinic environment" with the incidence of significant antibody levels strongly suggests that the risk of Legionella infection increases proportionately with increased clinic exposure time (P less than 0.05). Analysis of these data implies that Legionella may be present in the dental clinic environment, thus creating an increased risk for clinical personnel or patients.

Epidemiol Infect 1987 Aug;99(1):159-66
Widespread Legionella pneumophila contamination of dental stations in a dental school without apparent human infection.
Oppenheim BA, Sefton AM, Gill ON, Tyler JE, O'Mahony MC, Richards JM, Dennis PJ, Harrison TG

Following isolation of Legionella pneumophila from a special dental station water circuit, used primarily to cool high-speed dental drills which produce fine aerosols, a case finding and environmental survey was undertaken. Widespread colonization of the dental stations was found and the results suggested that amplification of the background levels of L. pneumophila was taking place within the stations. However there was no evidence for transmission causing human infection.

J Dent Res 1988 Jun;67(6):942-3
Serological examinations for antibodies against Legionella species in dental personnel.
Reinthaler FF, Mascher F, Stunzner D
Hygiene Institute, University of Graz, Austria.

Serum samples from 107 dentists, dental assistants, and dental technicians were examined with an indirect immunofluorescence test for antibodies to Legionella pneumophila SG1-SG6, L. micdadei, L. bozemanii, L. dumoffii, L. gormanii, L. jordanis, and L. longbeachae SG1 + 2. Thirty-six (34%) employees from dental personnel from 13 practices showed a positive reaction for antibodies to Legionella pneumophila. Only five samples (5%) from a control group (non-medical workers) were positive. Of the 36 positive serum samples, 13 (36%) reacted with Serogroup 6, 12 with SG 1 (33%), 12 with SG 5 (33%), and three with SG 4 (8%), and eight samples were positive for antibodies to other Legionella species. Dentists had the highest prevalence (50%) of L. pneumophila antibodies, followed by assistants (38%) and technicians (20%). These results indicate that dental personnel are at an increased risk of legionella infection.

J Hosp Infect 1990 Jul;16(1):9-18 Related Articles, Books
Published erratum appears in J Hosp Infect 1990 Nov;16(4):393
The efficacy of chlorination and filtration in the control and eradication of
Legionella from dental chair water systems.
Pankhurst CL, Philpott-Howard JN, Hewitt JH, Casewell MW
Department of Oral Microbiology, King's College School of Medicine and Dentistry, London.

The apparent failure of hyperchlorination and continuous dosing with chlorine to eliminate legionellae from a dental teaching hospital water supply prompted a prospective study to evaluate charcoal filters as a means of decontamination. Legionella pneumophila serogroup 10 and L. bozemanii serogroup 2 were isolated from dental units yielding 10(1)-10(3) colony forming units (cfu) ml-1 with total bacterial counts in the range 10(2)-greater than 10(4) cfu ml-1. After chair-side installation of charcoal filters bacterial contamination of the dental unit water was prevented and legionellae were initially not detected, but after 7 days the total count returned to pre-filtration levels of greater than 10(4) cfu ml-1; L. pneumophila serogroup 10 was eliminated but L. bozemanii serogroup 2 persisted. These results suggest that neither chlorination nor charcoal filtration deal adequately with the potential hazard of Legionella spp. in dental water.

Int Dent J 1998 Aug;48(4):359-68
Microbial contamination of dental unit waterlines: the scientific argument.
Pankhurst CL, Johnson NW, Woods RG
King's College Dental Institute, London, UK.

The quality of dental unit water is of considerable importance since patients and dental staff are regularly exposed to water and aerosols generated from the dental unit. The unique feature of dental chair water lines is the capacity for rapid development of a biofilm on the dental water supply lines combined with the generation of potentially contaminated aerosols. The biofilm, which is derived from bacteria in the incoming water and is intrinsically resistant to most biocides, then becomes the primary reservoir for continued contamination of the system. Dental water may become heavily contaminated with opportunistic respiratory pathogens such as Legionella and Mycobacterium spp. The significance of such exposure to patients and the dental team is discussed. There is at the present time, no evidence of a widespread public health problem from exposure to dental unit water. Nevertheless, the goal of infection control is to minimise the risk from exposure to potential pathogens and to create a safe working environment in which to treat patients. This paper evaluates the range of currently available infection control methods and prevention strategies which are designed to reduce the impact of the biofilm on dental water contamination, and are suitable for use in general practice. Bacterial load in dental unit water can be kept at or below recommended guidelines for drinking water (less than 200 colony forming units/ml) using a combination of readily available measures and strict adherence to maintenance protocols. Sterile water should be employed for all surgical treatments.

J Am Dent Assoc 1996 Aug;127(8):1188-93
Molecular techniques reveal high prevalence of Legionella in dental units. Williams HN, Paszko-Kolva C, Shahamat M, Palmer C, Pettis C, Kelley J Department of Oral and Craniofacial Biological Sciences, Baltimore College of Dental Surgery, Dental School, University of Maryland at Baltimore, USA.

Legionella bacteria are ubiquitous in freshwater aquatic systems, and humans are infected by them primarily through inhalation of contaminated aerosols. This study analyzed a total of 47 water samples from dental lines in private dental offices and university and hospital dental clinics for Legionella using the polymerase chain reaction, direct fluorescent antibody staining and culture techniques. The typical temperature of dental waterlines (23 C) combined with Legionella's ability to form biofilms, stagnation of the water in the lines and a low chlorine residual all potentially create a unique niche for this microorganism.

A web search was also quite rewarding. Among other things, I found the following:

Legionella, the cause of Legionnaires disease, is present in dangerously high concentrations in the majority of dental chair waterlines. A prominent California dentist recently died of Legionella; the strain found in his lungs was found in high concentrations in his office dental water lines. <end quote> (http://www.aquatechnology.net/dental_articles_3.html)

According to the ADA, "[s]cientific reports have not linked illness with water passing through dental waterlines." (http://www.ada.org/prac/position/waterqa.html) [sic!] Is this a case of suppressing the truth, or is it another instance of the dental establishment's contemptuous knee-jerk reactions to case reports? Should we have to wait for proper epidemiological studies involving thousands of subjects before the ADA accepts that the danger is quite tangible? (The tobacco industry's strategy.)

And further down in the same page, in response to a question about government regulations: "The ADA favors a voluntary goal and strongly opposes any effort to turn a scientific goal into a legal dictate. The dental profession has an excellent, proactive record on this and other safety issues."

Here are some other connected URLs:
http://hivdent.org/infctl/water1.htm http://www.hivdent.org/infctl/water2.htm http://www.pall.com/applicat/dental/lit_review.html http://www.micrylium.com/know2.htm http://www.regentmedical.com/uk_rgent/bacteria.htm http://www.dhmh.state.md.us/cpha/edcp/html/legion.html http://cythera.ic.gc.ca/spansweb/ndis/diseases/legi_e.html http://www.hc-sc.gc.ca/hpb/lcdc/publicat/ccdr/98vol24/dr2414ea.html http://www.q-net.net.au/~legion/Legionnaires_Disease_Updates..html

Per Dalen

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