Dentist blog from Delta Dental

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How to dispose of dental amalgam safely

Dental amalgam has safely served patients for more than 150 years. Its durability and affordability make it an acceptable dental material for restoring teeth. However, the presence of mercury in amalgam has raised some health and environmental concerns.

Mercury is a neurotoxin and is difficult to contain, so it has to be handled carefully to avoid exposure to humans and wildlife. What’s the best way to dispose of amalgam so that it doesn’t adversely affect the environment and is safe for dental team members to handle? Dental consultant Dr. Michael Tarighati gives us some best practices to follow.

About amalgam

Amalgam is a compound composed of about 50% liquid mercury and a powdered alloy of silver, tin, and copper mixed in a capsule. The mercury chemically reacts and binds with the alloy to form amalgam, which can be used to restore cavities.

When amalgam is placed on or removed from teeth, small amounts of mercury vapor are released, even when the patient is chewing.

 Exposure to high levels of mercury vapor — higher than those in fillings — can cause damage to the kidneys and brain.

Amalgam disposal laws

The U.S. Food and Drug Administration (FDA) categorizes dental amalgam as a Class II medical device and considers it safe for use on adults and children over 6 years old. It makes sure dental professionals handle the material safely and effectively. Each dental office must have the proper written discarding protocols for dental amalgam.

Effective July 14, 2020, dental practices must comply with the rules from the U.S. Environmental Protection Agency, which require dental facilities to install amalgam separators to capture the amalgam waste and remove at least 95% of all amalgam. This minimizes the amount that gets discharged into the wastewater system and the environment. Facilities that are exempt from these rules include those specializing in orthodontics, oral and maxillofacial surgery, periodontics, oral and maxillofacial radiology, prosthodontics and oral pathology. These practices don’t use amalgam in their procedures.

California has additional requirements that prohibit any rinsing or flushing any amalgam-containing trap or container in the sink, drain or toilet. In addition, to avoid placing amalgam waste, including defective amalgam capsules, extracted teeth with residual amalgam, or amalgam-containing traps in the biohazard waste or the regular solid waste containers, such as Isolyzer.

The FDA advises against replacing existing amalgam fillings that are in good condition unless it’s medically necessary. Delta Dental agrees with this advice. Do not remove amalgam fillings that are in good condition with no nearby decay present on the tooth. Removing them may result in loss of tooth structure and unnecessarily release mercury vapor.

Disposing of amalgam

Since mercury is considered toxic, you must follow certain safety protocols. To contain any mercury vapor while placing or removing amalgam from teeth, you need to use a rubber dam to isolate the teeth and use large amounts of water with high-volume suction alongside an air purifier to capture the vapors.

The rubber dam also acts as a barrier that prevents the patient from swallowing any particles, including amalgam.

To properly dispose of amalgam:

  1. Collect all amalgam that may hide in chairside traps, screens, vacuum pump filters or carrier instruments and place it in a separate airtight container labeled “Scrap dental amalgam.” Also include the office name, address, telephone number, and date it was first collected in the container.
  2. Don’t throw the container in the trash. Instead, send it to an EPA-licensed company such as Stericycle.
  3. Inspect, clean and maintain amalgam separators regularly according to the manufacturer’s recommendations and replace them when they are full. They must also comply with the American National Standards Institute (ANSI), American Dental Association (ADA), or the International Organization for Standardization (ISO).

With these protocols in place and committing to its strict consistent practices, you can make sure you treat your patients safely while protecting the environment from toxic and hazardous waste.

Infection control best practices

In light of recent global health emergencies such as the COVID-19 pandemic and monkeypox, and with flu season fast approaching, infection control is more crucial now than it’s ever been before.

Infection control prevents or stops the spread of infections in dental settings and is vital for the safety of your patients and dental team. It’s a process that involves continuing education, engineering protocols, vigilance and a commitment to follow proven step-by-step measures.

The following steps, from dental consultant Dr. Michael Tarighati, take into consideration the latest knowledge gained from the pandemic, particularly concerning aerosol spread, to help you achieve infection control best practices and ensure that your facility is clean and safe.

Patient treatment areas

Start of the day

  1. Wash your hands thoroughly with antibacterial soap and water before appointments and after any interruptions. Keep your fingernails trimmed and make sure they have smooth, filed edges to allow thorough cleaning and prevent glove tears.
  2. Wear personal protective equipment (PPE), including gloves, masks (level 1, 2, 3, N-95 respirators), protective eyewear with side shields, reusable water repellant lab coats or disposable gowns, head bouffant and face shields.
  3. Flush your high-speed handpiece hose for at least three minutes to clear any residual water in the tubing before connecting the handpiece. The CDC recommends using a dental unit water that meets the regulatory standards set by the Environmental Protective Agency (EPA) for drinking water, which must have fewer than 500 colony-forming units (CFU/mL) of heterotrophic water bacteria.
  4. Inspect the anti-retractive valve in each air-water syringe to prevent backflow of water.
  5. Fill each dental unit water container with distilled water.
  6. Flush water from the air-water syringe for one minute, and for at least 30 seconds between patients.
  7. Disinfect environmental surfaces with the “wipe-discard-wipe” technique. Wipe the surface with a disinfectant wipe to clean it, discard the wipe and then use another wipe to disinfect it. Do not spray disinfectant directly on surfaces, and limit spraying to procedures such as disinfecting dental impressions. Disinfect any surface with which you, your staff or your patients might come into contact, including:
    • Doctor and dental assistant chairs
    • Dental chair switches and arms
    • Lamp switches and handles
    • Hose ends
    • Bracket table handle edges
    • Handpiece holders and levers
    • Air-water syringe tip
    • Evacuator/ejection couplings
    • Drawer handles
    • Top of mobile unit
    • Countertops
    • Digital radiograph unit
    • Intraoral camera
    • Digital intraoral scanner
    • Composite applicator
    • Impression mixing cartridge dispenser gun
    • Reusable dental materials
  8. Cover the bracket table and countertop with a polyvinyl or cover and place a paper tray liner on the patient tray to minimize surface contact with contaminated disposables.
  9. Place disposable barrier sleeves on light curing units, digital radiograph sensors and other dental material syringes.
  10. Leave instruments unopened in their pouch or cassette.
  11. Calibrate the dental ultrasonic cleaner unit in the sterilization area with distilled water and enzymatic ultrasonic solution.
  12. Have your patient rinse with an antibacterial mouthwash before starting the procedure.
  13. Remove your gloves and wash your hands thoroughly before leaving the operatory.
  14. Discard reusable gowns in a dedicated hamper.

During each dental appointment

  1. Adhere to good work practices. Wash your hands if you leave the operatory, replace gloves that are torn, cut or punctured, and discard gloves before leaving the operatories.
  2. Clean and wipe down clinical contact surfaces between patient visits with an EPA-registered low-level or intermediate-level surface disinfectant. The benchmark organism used to assess intermediate (or higher) level disinfectants is Mycobacterium tuberculosis (TB), because it’s comparatively difficult to destroy. Tuberculocidal action ensures that the product will destroy all important pathogens found in medical and dental environments, referred to as “TB kill.”
  3. Avoid injury with sharp instruments and needles. Manage sharp instruments carefully and use a needle shield. Use the one-handed scoop technique to recap needles.
  4. Place all sharp items, such as needles, ends of sutures, burs and broken instruments, in appropriate red puncture-resistant containers mounted to the wall, and ensure that the container doesn’t reach its full capacity. Ideally, use Isolyzer in each dental operatory, ensuring that it’s within its six months of use.
  5. Place soiled gauze and cotton rolls in biohazard bags.
  6. Flush water from your high-speed handpiece hose and air-water syringe for at least 20 to 30 seconds between patient visits to clear any residual water in the tubing.
  7. Put on heavy utility gloves when transferring dirty instruments to the sterilization center. Each dental assistant team member must have dedicated utility gloves.
  8. Transfer contaminated instruments in a cassette.
  9. Remove gloves when you open cabinets and drawers to minimize cross contamination.
  10. Discard dirty reusable lab coats in a dedicated hamper.

End of the day

  1. Remove gloves and wash your hands. Put on heavy utility gloves when transferring a dirty instrument via cassette to the sterilization center.
  2. Discard reusable gowns in a dedicated hamper.
  3. Clean up disposables in the operatory. Wipe countertops, mobile cabinets and sinks with antibacterial soap and water.
  4. Disinfect each dental unit with disinfecting wipes, including the chair, operating doctor and dental assistant chairs, hoses and the bracket tabletop.
  5. For surgical procedures, remove and replace the screen in the saliva ejector and insert a new waterline cleansing tablet.
  6. Shock both the high-volume evacuation (HVE) line and slow-speed evacuation line with a gallon of water mixed with shocking agent.
  7. Shock the dental HVE system in each dental operatory with dental evacuation system agents.
  8. Drain the dental ultrasonic cleaner unit in the sterilization area. Don’t leave instruments out overnight and place them in sterilization pouches or cassettes.
  9. Housekeeping surfaces such as cabinets, walls, and floors must be cleaned and disinfected regularly with a low-level disinfectant with detergent, especially when spills occur or these surfaces are visibly soiled. Vacuum and mop the floors with a low-level disinfectant, such as bleach and water. Avoid sweeping the floor to prevent creating aerosol.

At the beginning of each week

  1. Disinfect each dental operatory with disinfecting wipes, including the chair, operating doctor and dental assistant chairs, hoses and the bracket tabletop.
  2. Run a spore test for the autoclave. Repeat the spore test if the first test is positive. If positive results continue, contact your dental supply company for maintenance.
  3. Maintain autoclave weekly cleaning protocols.
  4. Vacuum and mop the floors with a low-level disinfectant, such as bleach and water. Avoid sweeping the floor to prevent creating aerosol.

At the beginning of each month

  1. Maintain autoclave monthly cleaning protocols.
  2. Evaluate your eyewash station to ensure it’s functioning properly.
  3. Inspect the anti-retractive valve in each air-water syringe.
  4. Inspect your compressor unit.
  5. Inspect your amalgam separator unit.
  6. Inspect the water from each dental unit in each operatory, especially if you use tap water rather than distilled water.
  7. Inspect the air conditioner and heater air filters throughout the office.

Dental laboratory areas

  1. Change the lathe after polishing a removable denture, complete denture, nightguard, sports guard or snore guard appliance. Transfer the dirty lathe to the sterilization area to be sterilized.
  2. Change the acrylic or diamond bur after each adjustment of fixed or removable prosthodontic appliances, such as crowns, and transfer the dirty bur in a bur block to the sterilization area to be sterilized.
  3. Disinfect the countertops, the dental laboratory lathe machine, sandblaster unit and dental laboratory handpiece.
  4. Vacuum and mop the floors with a low-level disinfectant, such as bleach and water.
  5. Use your office washing machine to clean all dirty lab coats with bleach and detergent, and then put them in the dryer. Don’t wash patient blankets with lab coats.

Front office areas

  1. Ensure that dental team members who leave dental operatory areas discard their gowns or gloves to avoid cross-contamination to the front office and patient reception areas.
  2. Provide hand sanitizer, and ask patients to apply it when they check in.
  3. Reschedule patients who appear to be sick.
  4. Use gloves when using disinfecting wipes to disinfect the areas, including countertops, computer monitors, pens, the front door handle and the payment terminal machine.
  5. Vacuum and mop the floors with a low-level disinfectant, such as bleach and water.

By taking these measures, you’ll continue to keep your patients and team member’s health and wellbeing a priority, ensuring that they’re safe from spread of infection and illness. Remember, always adhere to Standard Precautions, which are the minimum infection prevention practices for all patient care, regardless of the status of their health, in any health care setting, including dentistry. For more information, review the infection control guidelines set forth by the CDC.

Meet Dr. Jessica Buehler, Director of Dental Affairs

Whether she’s motorcycling through the Alps or hiking through Southeast Asia to bring aid where it’s needed most, Dr. Jessica Buehler approaches what she does with passion, courage and commitment. That includes her work rewriting Delta Dental’s Quality Improvement Plan and bettering the oral health of members through her wellness webinars as Delta Dental’s Director of Dental Affairs.

We recently caught up with Dr. Buehler to discuss her work at Delta Dental, her time as a frontline provider during the early days of COVID and her dual passions for traveling and musical theater.

I think a lot of people, including even some dentists, might be surprised to learn that a dental insurance company like Delta Dental has dentists on staff. Can you tell us about the work you do for Delta Dental?

My work is to support our quality program. Insurance plans are regulated by the Department of Insurance and other regulatory bodies to ensure that the care is appropriate. It takes clinicians to be a part of that process so that key decisions about care and quality aren’t made by laypeople. They’re made by clinicians who have practiced and treated patients just like our dentists.

What initially led you to dentistry as a career?

I was overseas on the San Blas Islands off the coast of Panama working with an indigenous tribe on a summer mission trip. I volunteered to help a Panamanian dentist who was assigned by the government  to do health work on the island. I saw severe infections — people who had no access to care. It opened up my heart to this way to impact the world; it showed me how much dentists can improve people’s lives, not only in the U.S. but also overseas where people don’t have access to care.

What are the biggest rewards of your work now?

I feel my ability to impact oral health in this country is much bigger working for a plan. When you’re working as a chairside dentist, your impact is limited to only those patients you touch or the community events you volunteer at. Right now, I’m giving enrollee wellness webinars that are live-cast across the country to hundreds of enrollees at once. Having an impact on a stage that’s much bigger is really fun for me.

What do you miss most about being a chairside dentist? What do you miss least?

I miss the connection with my patients. You don’t realize when you go into dental school as a young person that your patients follow you for years and years. I saw couples get married and have babies. I saw babies grow into high schoolers. I saw couples get divorced and people pass. You are an intimate part of people’s lives over time. It feels like you’re checking in with old friends every time you see these patients. And when I went through those big life events like getting married and having a baby, my patients were there for me. I’m separated from that now, and I miss that.

In terms of what I miss the least: staffing. Staffing is impossible right now. Overall, dentistry is one of the hardest jobs in the world. It’s not for the faint of heart. 

I was so impressed to learn that you were a frontline provider during the early days of the COVID pandemic. It’s only been a couple years since then, but many of us have forgotten (or blocked out!) how very scary that time was, how many unknowns there were. Can you tell me about your work during that time?

When COVID hit, I was a regional clinical director supervising over 80 clinicians and specialists in Seattle. We were the epicenter of when it was first blowing up. Things were happening very fast, and there was very little guidance at that time, but we knew we had to do something to help. We had to make tough decisions about closing our offices: We had around 30 offices, and we went down to four.

The government was coming into dental offices and taking PPE, but we were expected to care for patients. My husband’s in construction, so he got a welding face shield for me and a construction and painting P100 respirator with a mask over the end. It wasn’t just about keeping myself safe. I was dealing with a lot of anxiety trying to keep my team safe. Some of my colleagues who worked for me had at-risk relatives at home. Some of them had health conditions. I was driving around the state to gather whatever supplies I could find in the construction world to provide to my doctors who were working those frontlines. It was a really scary time.

What do you think are some of the most important things Delta Dental can do to help maintain strong, positive relationships with dentists?

I think being empathetic to how hard dentistry is. It’s easy to go into a dental office and think a dentist is just a “tooth-counter.” I’ve had people say to me, “You make way too much money for what you do.” But a lot of people have no idea what dentists do! It’s a really hard job. It’s even hard on your body, too. You have to manage the emotions of your patients; you have to manage your staff. It’s challenging to be a business leader and a clinician and everything else.

Speaking of playing multiple roles, I was interested to learn that you have a background in musical theater. Can you tell me a little bit about that? Do you feel that your work in theater and performance helped inform your daily work as a dentist at all? Do the two pursuits have anything in common?

My parents always said, “Do whatever you want. We know you’ll succeed at whatever you decide.” So, I got really involved in musical theater and lighting design when I was in college. I loved the theater, but I realized I was a bit too organized and Type A to hang forever in that world…

I still love and appreciate the theater, but I come from a science family, and I almost felt dentistry was a calling. Once I got it into my brain, I couldn’t get it out. But, the things I learned in the theater — to ground yourself, to speak and perform with confidence — are really important and have helped me grow a lot as a provider.

What do you like to do in your free time?

I’m an avid reader. I run a book club for a community inclusion group at Delta Dental, Women@Delta. I love everything outdoors: stand-up paddleboarding, snow skiing, camping, hiking, wakeboarding, all of it. Just put me outdoors and I’m a happy girl! I love to travel. I did a motorcycle tour through the Alps, hitting seven countries in Europe with my dad. He’s passed now, so that’s one of my favorite memories… I love Thailand. I love Australia. I’ve done work in Southeast Asia in countries that aren’t even open to Western aid. I backpacked in and brought dental tools and taken teeth out, all sorts of crazy stuff. I have a family now, so I don’t do as many risky things now, but I still love to travel!

On-site quality assessment review checklist for 2022

In California, the Department of Managed Health Care (DMHC) requires that all dentists receive yearly on-site quality assessment (QA) reviews. These reviews evaluate how the many components of your practice compare to the expectations of dental professionals, regulatory agencies, dental educators and Delta Dental.

Your QA review will focus on two parts of your practice:

  1. Structural (about 20 minutes). Review of your facility and equipment, as well as emergency, sterilization and infection control protocols.
  2. Records (about an hour and 45 minutes). Review of patient treatment documentation for relevance and acceptability under current standards of patient care.

The easiest way to prepare for an on-site assessment is by getting acquainted with the aspects of a QA review. Follow the checklist below to understand what will be checked during your assessment.

Structural review

The structural review involves an assessment of the facility and equipment, as well as sterilization protocols.

Facility and equipment

  • Facility is clean and well maintained.
  • Dentist name and office hours are posted.
  • Procedure manual includes protocols for appointments, complaints, broken appointments and specialty referrals.
  • Accommodations exist for patients with disabilities, such as wheelchair access and a grab bar in the restroom.
  • Waterlines have anti-retraction valves installed and are maintained with properly flushed handpieces.


Sterilization and infection control

  • Staff is trained in infection control standards, and procedural logs are kept.
  • Gloves, masks, protective attire and eyewear are used appropriately.
  • Weekly biologic monitoring is conducted and records are kept.
  • Instruments and handpieces are properly sterilized, stored and labeled.

Safety and emergency procedures/equipment

  • Drugs, syringes and needles are properly stored, and a log is kept of drugs dispensed on site.
  • Required certifications are up to date.
  • A modern evacuation system exists for nitrous oxide.
  • Written office protocol includes staff responsibilities for evacuating patients in emergencies or natural disasters. The evacuation plan with clearly marked exits is displayed.
  • An active contact system can reach the dentist 24/7.
  • A portable emergency oxygen is available, full and there is a positive pressure valve and/or Ambu bag; staff are trained in its use.
  • Mercury hygiene and safety requirements are observed.
  • Medical emergency kit is up to date.

Records review

The records review involves a review of your patient care documentation.

Medical and dental history

  • Medical history forms include yes/no questions, identify patient’s existing conditions and contain comprehensive health information.
  • Dental history includes baseline information, TMJ/occlusion status, appliances, periodontal condition and results of soft tissue/oral cancer exam.

Treatment notes

  • Progress and treatment notes are legible and in ink.
  • Included, as appropriate, are: 
    • Referrals to specialists
    • Records forwarded or received
    • Anesthetic used (type, amount and concentration of any vasoconstrictor)
    • Medications prescribed
    • Laboratory instructions

Quality of care

  • Professionally acceptable standards of care are observed for: 
    • X-rays — adequate number, appropriate frequency, of diagnostic value, mounted and labeled
    • Treatment plan — in ink, consistent with diagnosis and exam findings, alternative and elective treatment documented with the patient’s choice and reason
    • Treatment sequence — in order of need
    • Informed consent — documentation that treatment plan was reviewed and patient understands risks, benefits, alternatives and costs; any refusal of recommended care is documented

Outcomes of care

  • Patient records demonstrate effectiveness of preventive care.
  • Overall comprehensive documentation demonstrates that treatment was provided as appropriate, including: 
    • Good prognosis for appropriate longevity
    • Evidence of need (x-rays, pocket charting, etc.)
    • Minimal unplanned treatment or retreatment
    • Referral to a specialist in a timely manner
    • Post-operative instruction given
    • Follow-up (pocket charting, x-rays, etc.)

After your review, you’ll be notified of the findings by mail. If you fail any part of the inspection, you’ll be asked to respond to show that you’ve corrected the error. Outstanding errors or repeated failures on follow up inspections may result in a referral to Delta Dental’s Peer Review Committee (PRC).

This list highlights just a few aspects of a QA review and is a useful tool to help you review your practice through the eyes of the QA examiner. Please refer to the Quality Management section of the Delta Dental Dentist Handbook for information on the Quality Assessment process and a list of all requirements. Together with your staff, you can evaluate your office policies and procedures and be even better prepared for a future on-site QA review. For more posts about QA reviews, check out the quality assessment category.

Ensuring your x-rays are safe and effective

Radiology is a key component of your dental practice. One of the most important aspects of taking x-rays is to ensure is that it’s done safely, both for the patient and for you and your staff. It’s also vital to make sure that proper procedures and practices are followed.

As part of our quality assessment reviews, we evaluate radiology practices and equipment. These on-site reviews are part of Delta Dental’s quality assessment program for contracted dentists in California, mandated by the California Department of Managed Health Care, and may also be done in other states as needed.

To make sure you pass with flying colors, here are some guidelines.


Whether you take x-rays with conventional x-ray film or use digital radiography, label all x-rays with this basic information:

  • Patient name
  • Date the x-ray was taken
  • Treating dentist’s name

Remember, x-rays must be labeled to be useful. Keep them accessible for several years to make it easier to review past and present oral conditions.

If you take digital x-rays, printed hard copy versions may not contain the necessary basic information. Check your software and be sure to add the information yourself if necessary.

Remember: If you use conventional x-rays (as opposed to digital images), always keep the originals. Send only duplicate films or x-ray copies of diagnostic quality to insurance carriers, specialists and patients.

Additional identification

Further labeling is needed when x-rays are taken for these reasons:

  • Endodontics. Label final x-rays as such, especially if you keep test x-rays as part of patient records.
  • Pre-cementation. Note this when taking x-rays for crown and bridge procedures.
  • Duplicates. These are highly recommended and should be identified as such.

Radiation hygiene

Radiation hygiene affects the health and safety of the patient and staff. Professionally acceptable standards include the following:

  • Any examinations are conducted by a dentist, and x-rays are prescribed prior to being taken.
  • Proper processing and exposure techniques are employed.
  • X-rays are appropriate to patient status, per current FDA guidelines.
  • All x-ray equipment is inspected and certified according to state regulations.
  • Equipment certificates are current and equipment inspection dates are posted.
  • Lead (or equivalent) aprons and cervical collars are used on all patients.

Apron use

Anyone who is in the x-ray room at the time of exposure (and is not behind a protective barrier) must wear a protective apron of not less than 0.25-millimeter lead or its equivalent. (An apron of 0.5-millimeter lead is preferable.)

Although there’s been recent conversation about whether the use of lead aprons during x-rays is necessary, their use is still required by most states.

Today, there are multiple options available for protective aprons and thyroid collars.

  • You can choose those made with lead, lightweight lead or a lead equivalent (lead-free).
  • Lead-free aprons are lighter, making them more comfortable, and disposal is easier on the environment, too.
  • Most lead-free aprons and collars are rated at the lead equivalency of 0.30 millimeters, which satisfies state regulations. You can verify the lead equivalent thickness by checking the label on the hem of the apron.

Both lead and lead-free aprons require proper storage to prolong their life and effectiveness.

  • Aprons should be hung without creases to prevent cracking.
  • The surfaces can be cleaned with a strong detergent.

Quality of care standards

Professionally acceptable standards for x-rays include the following:

  • An adequate number of x-rays are taken to make an appropriate diagnosis and treatment plan, per current FDA guidelines.
  • Patient refusal of x-rays is noted.
  • Bitewings don’t overlap contacts or include cone cuts that affect diagnostic value.
  • Periapical films show apices of the teeth and surrounding bone.
  • X-rays are diagnostic quality, taken at appropriate intervals for assessing health and pathology.
  • X-rays have no artifacts, chemical stains or scratches.
  • X-rays have good contrast.
  • Hard copy X-rays are mounted, labeled and dated.

Outcomes of care

Acceptable outcomes are evaluated by reviewing your patient records for successful completion and effectiveness. X-rays may be reviewed in the following instance:

  • Operative/crown and bridge. Sufficient x-rays were taken to evaluate diagnosis and restorative treatment.
  • Endodontics. Signs, symptoms and radiographic evidence of need is provided. Rubber dam use is documented in notes and working x-rays. There’s final film evaluation to determine properly instrumented and filled canal or canals.
  • Periodontics. Follow-up x-rays are taken after periodontic treatment, and x-rays are available to review treatment decisions.
  • Oral surgery: X-ray or soft tissue exam supports treatment rendered.

By following these simple steps, you can help ensure that your x-rays are helpful, safe and meet state and federal standards.

Maintaining your waterlines for your quality assessment

In 2016, there was an outbreak of bacterial infections in Californian children that was traced to oral surgeries at a particular clinic. The cause of the infections? Contaminated water.

Dental unit waterlines are prone to developing biofilm due to the size of the tubes, frequently stagnant water and low flow rates. Even in highly efficient water systems, bacteria are introduced into the tips of equipment every time the flow of water stops, due to fluid retraction. Within approximately 30 minutes of contamination, the concentration of bacteria can reach unacceptable levels. As a result, untreated dental unit water systems are breeding grounds for all kinds of common water bacteria.

Here’s how you can keep your waterline up to standards, even in water emergencies.

Cleaning your waterlines

A variety of solutions have been developed to address these issues, including filters and chemical solutions. Today, many offices use an independent water source that can be filled with clean or sterile water. However, it’s still important to clean waterlines to maintain safe levels of bacteria and your protocol for maintaining sanitary waterlines is evaluated as part of a quality assurance (QA) review.

Waterline flushing is a mandatory daily practice. Many regulations, including the California Code of Regulations, require that waterlines, handpieces, scalers, air/water syringes and similar devices be flushed for two minutes at the beginning of each workday and for 20 seconds between each patient. Installing a dedicated sterile water supply can help greatly, but the flushing requirement must still be met.

Preparing for a water emergency

Natural disasters, failure in the municipal water system or even deliberate tampering can result in public water contamination and a boil water advisory. Follow these steps to prepare for an emergency that may affect your office water supply:

  • Research and document your local water company’s recommendation for flushing water lines to reduce contamination.
  • List all the ways your office uses water to help you identify where water use is critical (such as for sterilization) and where it can be restricted during an emergency (for example, for mouth rinsing, because bottled water can be used).
  • Ensure that you have an adequate supply of bottled water on hand and a supply of water purification tablets to use with boiled water.
  • Take steps now to conserve water where possible to help better handle a potential water shortage or disruption in service.
  • Review the Emergency Water Supply Planning Guide for Hospitals and Health Care Facilities from the Centers for Disease Control and Prevention. Consider printing this guide in case you need to access it at a time when the internet or power is down at your practice.

During a water emergency

You may receive an alert that water is contaminated and must be boiled before use, or you may find that there is no water service at all. When water is not available, you’ll most likely need to postpone treating non-emergency patients. To keep your office as functional as possible during an emergency, here’s what you should and should not do:


  • Place “Do not use” labels on taps and other equipment that use public water.
  • Have patients rinse with bottled water.
  • Use only tap water that has been boiled to a strong, rolling boil for one minute or more and cooled.
  • Use alcohol-based or antiseptic cloths for hand washing, or soap and bottled water for visibly soiled hands.


  • Use any equipment that uses water from the public water system (such as the dental unit, ultrasonic scaler, etc.).
  • Use water from a tap to wash hands or clean instruments.

When public water service is restored

After an emergency, the first thing you should do with your waterlines is flush all the lines that bring water into your office for two to five minutes (the flush time depends on the type and extent of the plumbing system that leads to the office). Then, follow the manufacturer’s instructions to disinfect the entirety of your dental unit waterlines.

Water is a key component of daily operation in your practice, so make sure it’s clean and safe.

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