Bacterial contamination of dental chair units in a

modern dental hospital caused by leakage from

suction system hoses containing extensive biolm
M.J. ODonnell
a
, C.M. Tuttlebee
a
, F.R. Falkiner
b
, D.C. Coleman
a,
*
a
Microbiology Research Unit, Department of Oral Surgery, Oral Medicine and Oral Pathology, School of
Dental Science & Dublin Dental Hospital, University of Dublin, Trinity College, Lincoln Place, Dublin 2,
Republic of Ireland
b
Department of Laboratory Medicine, The Adelaide and Meath Hospital incorporating the National
Childrens Hospital, Tallaght, Dublin 24, Republic of Ireland
Received 1 June 2004; accepted 6 October 2004
Available online 28 January 2005
KEYWORDS
Dental chair unit;
Suction system;
Biolm; Pseudomonas
aeruginosa;
Serotyping; DNA
ngerprinting
Summary Within six months of opening of the new Dublin Dental Hospital
in September 1998, areas of corrosion were observed on many of the
baseplates of the hospitals 103 dental chair units (DCUs) at the site of
attachment of the suction hoses. The corroded areas were heavily
contaminated with Pseudomonas spp. and related genera posing a risk of
cross-infection, particularly for immunocompromised patients. These
species were used as marker organisms to investigate the source of the
contamination. P. aeruginosa was the predominant species recovered from
41 selected DCU baseplates (61% prevalence), whereas P. putida (46%
prevalence) and P. aeruginosa (43% prevalence) were predominant at the
attachment ends of 37 selected high-volume suction hoses. Forty-one
selected isolates of P. aeruginosa from 13 DCU baseplates, 16 high-volume
suction hoses and 12 coarse lter housings (another suction system site)
from 19 separate DCUs were serotyped to determine the similarity of
isolates at each site. The majority of isolates (68.3%) belonged to serotype
O:10, while the remainder belonged to serotypes O:6 (7.3%), O:11 (7.3%),
O:14 (9.8%) and O:5/O:16 (7.3%). Of the isolates from DCU baseplates,
additional isolates with the same serotype were recovered from other
suction system sites in 10/13 (77%) cases. Isolates of only one serotype were
recovered from each of the 19 DCUs investigated. Forty-one serotyped
isolates were also subject to computer-assisted analysis of SpeI-generated
DNA ngerprint proles, and similarity coefcient (S
AB
s) values were
calculated for each pairwise combination of isolate proles. The data
Journal of Hospital Infection (2005) 59, 348360
www.elsevierhealth.com/journals/jhin
0195-6701/$ - see front matter Q 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: C353 1 6127276; fax: C353 1 6127295.
E-mail address: dcoleman@dental.tcd.ie
obtained showed that the isolates consisted of two distinct main
populations, each containing separate clades corresponding to specic
serotypes. Serotype O:6 (three isolates), O:11 (three isolates) and O:5/O:16
(three isolates) belonged to a single strain in each case. Serotypes O:14 (four
isolates) and O:10 (28 isolates) belonged to two strains in each case. The two
serotype O:10 strains, termed ngerprint groups I (four isolates from three
DCUs) and II (24 isolates from 10 DCUs), were the most distantly related of
all the strains identied. These ndings demonstrated that the hospital DCUs
had become colonized with a small number of P. aeruginosa strains, one of
which (serotype O:10, ngerprint group II) predominated. These results also
conrmed that DCU baseplate contamination was most likely to be due to
leakage from suction system hoses at the baseplate attachment sites,
probably due to loosening during use. Replacement hose connectors that
rmly retained the suction hoses in the attachment sites so that they could
not be loosened by movement of the suction hoses solved this problem, and
eliminated further contamination of the DCU baseplates.
Q 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights
reserved.
Introduction
The dental chair unit (DCU) is a complex, modular
item of equipment that is integral to the practice of
modern dentistry. The primary functions of the DCU
are to provide physical support for the entire body
of the dental patient and to allow for smooth and
efcient dental team interaction during treatment
of the patient. Essentially, the DCU consists of the
dental chair, a pedestal unit providing supply and
control of instruments and ancillary attachments,
and the oral evacuation or suction system. The
suction system is designed to remove saliva, blood,
amalgam and other debris generated during oper-
ative dentistry from the mouth. The use of high-
speed cutting instruments during dental treatment
generates frictional heat that could lead to over-
heating of teeth and consequent damage to dental
pulp. To prevent this from happening, dental unit
handpieces are equipped with integrated spray
devices for cooling. These provide cooling jets of
water that can give rise to ne aerosols during
operation of high-speed rotary instruments and
ultrasonic scalers. Use of the suction system
reduces the levels of aerosols, spray and splatter
generated during dental treatment.
15
In many modern DCUs, the suction system
consists of two suction hoses attached to a vacuum
source supplied to the body of the DCU. The high-
volume suction hose is used to remove debris and
dental unit water, and to reduce spray and aerosols,
whereas the low-volume suction hose, or saliva
ejector, is used mainly to remove excess uids from
the patients mouth, especially if the clinician is
working unassisted.
4,6,7
In a dental hospital
equipped with many DCUs, a central vacuum plant
provides the suction to the DCUs through a network
of pipes. The high- and low-volume suction hoses
attached to each DCU are connected to a common
suction pipe within the pedestal unit of each DCU
through which waste uids are passed to a central
collection vessel. Each DCU is also equipped with an
amalgam trap to remove pieces of dental amalgam,
and a coarse lter to remove particulate matter.
Both of these devices are connected to the suction
system pipework within each DCU. By its very
nature, the DCU suction system, including suction
hoses, becomes contaminated with oral micro-
organisms. Furthermore, because the suction sys-
tem hoses and pipework are frequently wet, they
provide an environment conducive to the growth
and proliferation of biolm. For these reasons, DCU
suction systems have to be disinfected regularly.
8
Shortly after the opening of the new Dublin
Dental Hospital building in 1998, areas of rust or
corrosion were observed on the pedestal units at
the site of attachment of the suction hoses on many
of the Planmeca Prostyle Compact DCUs with which
the hospital is equipped. Preliminary investigations
revealed that the areas of corrosion were often
damp, were heavily contaminated with Pseudomo-
nas spp. and related bacterial species, and con-
stituted a potential risk of cross-infection in the
dental hospital clinics, particularly because of the
increasing number of immunocompromised and
medically compromised patients seeking dental
treatment.
911
The purpose of the present study
was to investigate the source of the bacterial
contamination of DCU baseplates and to eliminate
it.
Bacterial contamination of dental chair units 349
Materials and methods
Dental chair units
Dublin Dental Hospital is equipped with 103
Planmeca Prostyle Compact (Planmeca Oy, Hel-
sinki, Finland) DCUs (Figure 1). In these DCUs, the
high- and low-volume suction hoses are connected
to the pedestal of the DCUs with specially designed
plastic connectors that interface with receivers in
the DCU through a metal baseplate underneath the
ceramic spittoon (Figure 1). To secure the suction
hoses to the DCU, the plastic connectors are pushed
onto the end of the suction hoses and then pushed
through machined orices in the baseplate and into
the hose receivers.
All 103 DCUs were examined visually for the
presence of corrosion around the suction hose
attachment site on the DCU pedestal. Forty-one
DCUs were selected for microbiological sampling.
The internal and external surfaces of the high- and
low-volume suction hoses from all 41 selected DCUs
were examined visually at both ends for the
presence of staining or deposits suggestive of
biolm. Similarly, the plastic connecting collars
used to attach the suction hoses to the DCUs were
examined visually for biolm (Figure 2).
Microbiological sampling of DCUs
The DCU baseplate orices and adjacent areas of all
41 selected DCUs were sampled using sterile cotton
wool swabs (Venturi, Transystem, Copan, Italy).
Surfaces were swabbed thoroughly using both back
and forth and perpendicular strokes. Following
sampling, each swab was placed in a tube of sterile
hydrated sodium alginate supplied with the swab,
Figure 1 View of a Planmeca Prostyle Compact dental
chair unit. The pedestal unit (P) is located on the left
under the ceramic spittoon. The high-volume (HV) and
low-volume (LV) suction hoses are indicated. The arrow-
heads indicate the attachment sites of the suction hoses
under the spittoon.
Figure 2 Views of sections of a Planmeca Prostyle
Compact dental chair unit (DCU) showing suction hose
attachment sites. (a) Portion of a pedestal section with
the ceramic spittoon removed showing the high-volume
(left) and low-volume (right) suction hoses attached to
the DCU by plastic connectors. Arrows indicate areas of
corrosion visible on the side section of the metal
baseplate through which the suction hoses are con-
nected. (b) View of DCU baseplate in situ photographed
from underneath showing the orices into which the
suction hoses conectors are inserted. Evidence of
corrosion is visible around the orices and adjacent
areas. (c) Suction connectors attached to a high-volume
(left) and low-volume (right) suction hose. The staining
evident on both connectors was due to biolm formation
by Pseudomonas spp. and related bacterial species.
M.J. ODonnell et al. 350
labelled, packaged and immediately transferred to
the hospitals microbiology laboratory for culture.
All swabs were plated on to culture media within 2 h
of sampling. Swab samples were also taken fromthe
coarse lter housing of 12 separate DCUs. The
coarse lter housing is part of the suction system
that contains a lter for trapping particulate
matter. It is located within the pedestal part of
the DCU, distant from the suction hoses.
Culture media and growth conditions
Preliminary experiments indicated that corroded
DCU baseplates were heavily contaminated with
Pseudomonas spp. and related bacterial species
following culture of swab samples on nutrient agar
plates and subsequent Gram stain and formal
identication. For this reason, Pseudomonas spp.
and related bacterial species were selected as
marker organisms for DCU contamination. Swab
samples were plated on to Pseudomonas Agar base
(PAB, Oxoid, Basingstoke, Hampshire, UK) culture
medium and on to PAB medium supplemented with
cetrimide (10 mg/mL), fusidic acid (10 mg/mL), and
cephaloridine (50 mg/mL) to select for the growth
of Pseudomonas spp. and related species. Following
incubation at 30 8C for 48 h, the plates were
examined and the number of colony forming units
(cfu) were counted and recorded. An incubation
temperature of 30 8C was chosen as preliminary
experiments determined that this temperature
facilitated the growth of some environmental
bacteria that grew poorly or not at all at 37 8C.
The characteristics of different colony types pre-
sent (i.e. pigmented colonies, mucoid colonies,
colonies with serrated edges, spreading colonies
etc.) and their relative abundance were also
recorded. Selected colonies of each type present
were stored on nutrient agar slants in bijou bottles
at room temperature in the dark to await further
analysis.
Chemicals
All chemicals were of analytical grade and, unless
otherwise specied, were purchased from Sigma-
Aldrich (Tallaght, Dublin, Ireland).
Bacterial species identication
Prior to testing, bacterial isolates were inoculated
on to fresh PAB agar plates and incubated as above
for 48 h. Following incubation, isolates were Gram
stained and tested for oxidase production using the
BBL DrySlidee system (Becton Dickinson and
Company, New Jersey, USA) according to the
manufacturers instructions. As the majority of
isolates tested were Gram-negative rods, formal
identication was undertaken using the API 20 NE
system (bioMerieux, Marcy-lEtoile, France).
Serotyping P. aeruginosa isolates
P. aeruginosa isolates identied using the API 20 NE
system were serotyped by slide agglutination using
17 P. aeruginosa O-specic antisera supplied by the
Public Health Laboratory Service, Laboratory of
Hospital Infection, Central Public Health Labora-
tory, Colindale, London, UK. The antisera were
supplied as individual antisera and as four pools of
antisera. All P. aeruginosa isolates were also tested
for spontaneous agglutination with sterile saline.
Isolates were serotyped on two separate occasions.
DNA ngerprinting of P. aeruginosa isolates
High-molecular-weight chromosomal DNA from P.
aeruginosa isolates was prepared in agarose plugs
by the method of Grothues et al.
12
except that the
plugs were incubated for 72 h at 55 8C with the
buffer being changed daily. Following preparation,
DNA in plugs was digested with SpeI at 37 8C for 7 h
in SpeI buffer (Promega Corp., Madison, WI, USA)
according to the manufacturers instructions. Fol-
lowing digestion, DNA fragments in the plugs were
separated in 1.1% (w/v) agarose gels by pulsed eld
gel electrophoresis (PFGE) using the CHEF Mapper
System (Bio-Rad, Richmond, CA, USA) according to
the method of Romling et al.
13
Bacteriophage l
phage DNA oligomers (New England BioLabs,
Hitchin, UK) were applied to the outermost lanes
of each gel as molecular size markers. High-
molecular-weight DNA in agarose plugs from eight
selected P. aeruginosa isolates was also separately
digested with XbaI at 37 8C for 15 h in XbaI buffer
(Promega) according to the manufacturers instruc-
tions. Following digestion, DNA fragments were
separated by PFGE in 1% (w/v) agarose gels made
with ultra-pure DNA-grade agarose (Bio-Rad) in
0.5!Tris-Borate-EDTA (TBE) buffer in two ramps
for 20 h at 14 8C. Pulse times were 5 s for the rst
10 h and 10 s for the nal 10 h, with a eld strength
of 6 V/cm (modied from Hla et al.
14
). Following
electrophoresis, gels were stained with 0.5 mg/mL
ethidium bromide for 45 min, destained in water for
30 min and examined under ultraviolet light using a
transilluminator (UVP, Ultraviolet Products, Cali-
fornia, USA). DNA ngerprint images were saved
onto computer diskette using the Gel Documen-
tation System ImageStore 7500 version 7.22 (UVP).
Bacterial contamination of dental chair units 351
Computer-assisted analyses of ngerprint patterns
were performed using the DENDRON software
package version 2.3 (Solltech, Iowa City, IA, USA)
as described previously.
1517
SpeI- and XbaI-gener-
ated DNA ngerprints from the predominant hospi-
tal P. aeruginosa serotype O:10 were used as
references on each gel used for computer-assisted
analysis. Similarity coefcients (S
AB
s) based on band
position alone were calculated for each pairwise
combination of isolate patterns according to the
formula S
AB
Z2E/(2ECaCb), where E is the
number of bands shared by strains A and B, a is
the number of bands unique to A, and b is the
number of bands unique to B.
17
An S
AB
of 0.0
represents totally different patterns with no corre-
late bands, an S
AB
of 1.00 represents identical
patterns and S
AB
s ranging from 0.01 to 0.99
represent patterns with increasing proportions of
bands at the same positions.
Results
DCU corrosion and extensive bacterial
contamination
Visual examination of all 103 DCUs in Dublin Dental
Hospital revealed the presence of areas of corrosion
around the suction hose attachment orices. In the
vast majority of cases (97/103), corrosion was
minor, consisting of isolated spots of rust around
the circumference of the suction hose orices
[Figure 2(a) and (b)]. However, six DCUs located
in the accident and emergency (AE) clinic exhibited
extensive corrosion around the circumference of
the suction hose orices as well as in adjacent areas
of the baseplates. DCUs in the AE clinic are the most
extensively used of all the DCUs in the hospital.
Culture analysis of samples from DCU
baseplates and high-volume suction hoses
Swab samples taken from 41 selected DCUs from
the dental hospital clinics were cultured on PAB
agar medium, both with and without selective
supplements, to select for Pseudomonas spp. and
related bacterial species in order to investigate
levels of bacterial contamination. Swab samples
were taken from the DCU baseplate at the site of
attachment of the suction hoses for all 41 DCUs and
any adjacent areas that exhibited evidence of
corrosion. Overall, there was no signicant differ-
ence in the density or types of bacterial colonies
recovered on both media. In the majority of
cases, the colonies were mucoid, spreading and
pigmented with green, yellow or brown colour-
ation. For all 41 DCUs sampled, the culture plates
yielded semiconuent (R500 cfu/swab) or conu-
ent (R1000 cfu/swab) growth.
Following subculture, a total of 53 individual
isolates were identied with the API 20 NE system
from the 41 DCU baseplates tested. In the case of
six DCUs, two isolates of the same species were
selected based on differences in colony morphology
or colony colour, including P. aeruginosa (four
DCUs), P. putida (one DCU) and Comamonas
acidovorans (one DCU). It was found that the
predominant organism isolated was P. aeruginosa.
Of the 41 DCU baseplates sampled, 25 baseplates
(60.9%) yielded P. aeruginosa, either alone (20/41,
48.8%) or in combination with other Gram-negative
bacterial species (5/41, 12.2%) (Table I). The
internal lumen of the high-volume suction hose
and connectors from 37 DCUs were also sampled for
the presence of Pseudomonas spp. and related
species by culture analysis in order to determine
whether similar organisms were present in the
attachment ends of the suction hoses adjacent to
the hose attachment sites. Visual examination of
the plastic connectors used to attach the suction
hoses to the DCUs revealed the presence of
extensive green/brown-coloured biolm [Figure
2(c)]. Similar deposits were visible inside the
lumen of the suction hoses following removal of
the plastic connectors. In 29/37 (78.4%) DCUs
sampled, the culture plates yielded conuent
Table I Recovery of bacterial species from 41 dental chair unit (DCU) suction hose orice baseplates
Single bacterial
species isolated
No. of DCUs Two bacterial species isolated No. of DCUs
P. aeruginosa 20 P. aeruginosa and P. putida 2
P. putida 8 P. aeruginosa and S. maltophilia 2
S. maltophilia 4 P. aeruginosa and P. uorescens 1
P. uorescens 1 P. putida and P. uorescens 1
C. acidovorans 1
B. bronchiseptica 1
P., Pseudomonas; S., Stenotrophomonas; C., Comamonas; B., Bordetella.
M.J. ODonnell et al. 352
growth (R1000 cfu/swab). The remainder yielded
between 10 and 500 cfu/swab. As was found with
samples fromthe DCU baseplates, in the majority of
cases, the colonies were mucoid, spreading and
pigmented with green, yellow or brown colour-
ation. In total, 68 separate bacterial isolates from
the 37 DCU attachment-end suction hoses sampled
were identied. In the case of seven DCUs, two
isolates of the same species were selected based on
differences in colony morphology, including P.
putida (four DCUs), Stenotrophomonas maltophilia
(one DCU) and P. uorescens (one DCU). Nineteen
DCU high-volume suction hoses (51.4%) yielded a
single bacterial species, whereas the remaining 18
DCU hoses (48.6%) yielded multiple bacterial
species (Table II). P. putida was the predominant
bacterial species recovered from the DCU hoses and
was recovered from 19/37 hoses sampled (51.4%),
either alone (6/37, 16.2%) or in combination with
other bacterial species (13/37, 35.1%). P. aerugi-
nosa was the second most prevalent species
recovered (16/37, 43.2%), either alone (8/37,
21.6%) or in combination with other bacterial
species (8/37, 21.6%) (Table II). A small number of
isolates of other bacterial species was also recov-
ered from the attachment ends of the high-volume
suction hoses, including Burkholderia cepacia, C.
acidovorans, Alcaligenes xylosoxidans and CDC
group IVc-2 (Table II).
Serotyping of P. aeruginosa isolates
Selected isolates of P. aeruginosa recovered from
corroded baseplates and the attachment ends of
high-volume suction hoses in separate DCUs were
serotyped in order to determine whether
antigenically similar isolates were present in
different DCUs and at different sites in individual
DCUs. Twelve additional P. aeruginosa isolates
recovered from the coarse lter housing within
separate DCUs were also studied. Forty-one separ-
ate P. aeruginosa isolates recovered from 19 DCUs
were serotyped (Table III). The majority of the
isolates (28/41, 68.3%) belonged to serotype O:10
and the remainder belonged to four other sero-
types, including O:6 (7.3%), O:11 (7.3%), O:14
(9.8%) and O:5/O:16 (7.3%) (Table III). Of the 19
DCUs included in this part of the study, 13 yielded P.
aeruginosa from two or three of the separate
suction system sites sampled. Of these 13 DCUs,
10 yielded P. aeruginosa isolates belonging to
serotype O:10 from all the sites sampled (Table
III). Three separate DCUs yielded isolates of O:6,
O:11 or O:5/O:16 from the three sites sampled,
respectively (Table III).
Of the 13 P. aeruginosa isolates from separate
DCU baseplates that were serotyped, additional
isolates with the same serotype were recovered
from other sites in the respective DCUs in 10 (76.9%)
cases (Table III). Overall, only P. aeruginosa
isolates of one serotype were recovered from
each of the 19 DCUs investigated (Table III). All of
these ndings provided evidence that the organisms
recovered from the DCU baseplates originated from
within the respective DCU suction systems.
DNA ngerprinting of P. aeruginosa isolates
The 41 P. aeruginosa isolates that were serotyped
(Table III) were also subject to SpeI-generated DNA
ngerprinting and computer-assisted analysis of
ngerprint proles with the computer program
Table II Recovery of bacterial species from the internal lumens of the attachment ends of high-volume suction
hoses and connectors in 37 dental chair units (DCUs) in Dublin Dental Hospital
Single bacterial
species isolated
No. of
DCUs
Two bacterial
species isolated
No. of
DCUs
Three bacterial
species isolated
No. of
DCUs
P. aeruginosa 8 S. maltophilia and
P. putida
5 P. aeruginosa,
P. putida and S. maltophilia
1
P. putida 6 P. aeruginosa and
P. putida
3 P. putida, P. aeruginosa and
C. acidovorans
1
S. maltophilia 3 P. putida and
CDC Gr IV C2
a
1 P. aeruginosa, P. uorescens
and A. xylosoxidans
1
P. uorescens 2 S. maltophilia
and P. uorescens
1 P. putida, S. maltophilia and
C. acidovorans
1
S. maltophilia and
P. aeruginosa
1 P. putida, P. uorescens
and P. aeruginosa
1
S. maltophilia and
B. cepacia
1 P. aeruginosa, S. maltophilia
and P. uorescens
1
P., Pseudomonas; S., Stenotrophomonas; C., Comamonas; B., Burkholderia; A., Alcaligenes.
a
CDC group IVc-2 are short to medium-sized Gram-negative rods that stain irregularly.
18
Bacterial contamination of dental chair units 353
DENDRON. In general, isolates of different sero-
types yielded distinctly different ngerprint pat-
terns, whereas isolates with the same serotype
yielded identical or closely related patterns, apart
from O:10 and O:14 isolates. To obtain an objective
determination of the relationship between the
isolates investigated, S
AB
values were computed
for every possible pairwise combination of isolates,
and these data (Table IV) were used to construct a
dendrogram showing the relationships between all
of the isolates (Figure 3). The 28 serotype O:10
isolates could be readily divided into two clearly
distinct DNA ngerprint groups, termed ngerprint
groups I (four isolates) and II (24 isolates), respect-
ively (Table III and Figure 3). The four ngerprint I
isolates yielded identical ngerprint patterns (S
AB
Z
1.0) and were recovered from three separate DCUs,
whereas the 24 ngerprint group II isolates were
recovered from 10 separate DCUs (Table III). Of
these 10 DCUs, seven yielded ngerprint group II
isolates from two or more of the three sites
sampled. Some variability in the DNA ngerprint
prole of the ngerprint group II isolates was
observed, but all were highly related with an
average S
AB
value of 0.93 (range 0.821.0) (Figure
3 and Table IV). Interestingly, the ngerprint group
I and II isolates (all serotype O:10) were very
distinct and clearly divided at an S
AB
value of 0.24
(Figure 3). The three serotype O:6 isolates yielded
identical ngerprint proles (S
AB
Z1.0), termed
ngerprint group III, as did the three O:5/O:16
isolates, termed ngerprint group IV. Two of the
three O:11 isolates yielded identical ngerprint
proles (ngerprint group V) and the third differed
by a single band (average S
AB
Z0.98) (Table III). The
four O:14 isolates yielded two distinct ngerprint
patterns, termed ngerprint groups VI (three iso-
lates; average S
AB
Z0.95) and VII (one isolate),
respectively (Table III), which separated from the
other three O:14 isolates at an S
AB
Z0.67 (Figure 3
and Table IV). These ndings provided evidence
that individual isolates within each of these
ngerprint groups belonged to the same strain in
each case.
Multiple isolates (18 single colonies recovered on
primary isolation plates) of the same P. aeruginosa
Table III Serotypes and ngerprint groups of Pseudomona aeruginosa isolates recovered from three sites in 19
dental chair units (DCUs) in Dublin Dental Hospital
DCU
a
Baseplates Attachment end of high-
volume suction hose
b
Coarse lter housing
Serotype DNA type Serotype DNA type Serotype DNA type
2.1.1 NS NI O:10 I
2.1.5 NI O:10 I NI
2.1.8 NS O:10 I O:10 I
2.2.1 O:10 II O:10 II NI
2.2.2 O:10 II O:10 II O:10 II
2.2.3 O:10 II O:10 II O:10 II
2.2.4 NS O:10 II O:10 II
2.2.5 O:10 II O:10 II O:10 II
2.2.6 NS O:10 II NI
2.2.8 O:10 II O:10 II O:10 II
2.3.5 O:6 III O:6 III O:6 III
2.4.5 NS O:10 II O:10 II
2.4.6 O:10 II O:10 II O:10 II
2.5.4 O:5/O:16
c
IV O:5/O:16
c
IV O:5/O:16
c
IV
A/E 2 O:11 V O:11 V O:11 V
A/E 3 NI O:10 II O:10 II
A/E 9
d
O:14 VI NI NI
O:14 VII
A/E 10 O:14 VI NI NI
A/E 11 O:14 VI NI NI
NI, P. aeruginosa not isolated from site; NS, site not sampled.
a
The rst digit refers to the clinic number, the second digit refers to the bay number and the third digit refers to the chair number.
b
The high-volume suction hoses are attached to the DCU baseplate using a hose connector.
c
Serotypes O:5 and O:16 share similar trisaccharide backbone repeat units and the respective antisera cross-react.
d
Two P. aeruginosa isolates fromDCU AE9 that were distinguishable on the basis of colony morphology were investigated. The two
isolates yielded distinctly different SpeI-generated ngerprint proles (S
AB
Z0.67) indicating that the isolates belonged to separate
strains.
M.J. ODonnell et al. 354
Table IV Matrix showing similarity coefcient (S
AB
) values for pairwise combinations of Pseudomonas aeruginosa isolates from different ngerprint groups
Isolates
a
2.1.5H
2.2.1B 0.14
2.2.2H 0.14 0.88
2.2.3B 0.21 0.94 0.88
2.2.3H 0.14 0.91 0.91 0.91
2.2.4C 0.50 0.91 0.85 0.91 0.88
2.2.4H 0.14 0.94 0.88 0.94 0.91 0.97
2.2.5C 0.15 0.91 0.85 0.91 0.88 0.88 0.91
2.2.6H 0.14 0.94 0.94 0.94 0.97 0.91 0.94 0.91
2.4.5C 0.14 0.94 0.82 0.88 0.86 0.91 0.88 0.85 0.88
2.4.5H 0.21 0.94 0.88 0.94 0.91 0.91 0.94 0.91 0.94 0.88
2.4.6H 0.15 0.91 0.97 0.91 0.88 0.88 0.91 0.88 0.91 0.85 0.91
2.3.5c 0.31 0.31 0.25 0.31 0.36 0.39 0.38 0.32 0.31 0.31 0.31 0.26
2.5.4B 0.27 0.61 0.56 0.61 0.65 0.63 0.61 0.57 0.61 0.61 0.61 0.57 0.47
AE2B 0.07 0.59 0.53 0.53 0.57 0.55 0.53 0.55 0.59 0.59 0.59 0.48 0.38 0.56
AE2C 0.07 0.61 0.55 0.55 0.59 0.56 0.55 0.56 0.61 0.61 0.61 0.50 0.39 0.51 0.97
AE9Bi 0.46 0.31 0.25 0.38 0.30 0.32 0.31 0.32 0.31 0.31 0.38 0.26 0.33 0.35 0.44 0.45
AE11B 0.46 0.31 0.25 0.38 0.30 0.32 0.31 0.32 0.31 0.31 0.38 0.26 0.33 0.35 0.44 0.45 0.93
AE9Bii 0.48 0.46 0.34 0.46 0.39 0.41 0.40 0.41 0.40 0.40 0.46 0.35 0.18 0.38 0.34 0.35 0.67 0.67
Isolates
a
2.1.5H 2.2.1B 2.2.2H 2.2.3B 2.2.3H 2.2.4C 2.2.4H 2.2.5C 2.2.6H 2.4.5C 2.4.5H 2.4.6H 2.3.5C 2.5.4B AE2B AE2C AE9Bi AE11B AE9Bii
I II III IV V VI VII
Where several isolates from a particular ngerprint group were indistinguishable (i.e. shared all ngerprint bands in common; S
AB
Z1), a representative was selected for matrix
construction.
a
The provenance of isolates is shown in Table III. H, attachment end of a high-volume suction hose; B, DCU baseplate; C,coarse lter cage housing.
B
a
c
t
e
r
i
a
l
c
o
n
t
a
m
i
n
a
t
i
o
n
o
f
d
e
n
t
a
l
c
h
a
i
r
u
n
i
t
s
3
5
5
serotype O:10 strain (with identical or very similar
SpeI-generated ngerprint proles) recovered in
each case from the high-volume suction hoses of
three separate DCUs yielded an average S
AB
value of
0.97 (S
AB
range 0.941.0).The relationship between
eight selected ngerprint I (six isolates) and II (two
isolates) isolates was also investigated by XbaI-
generated DNA proling following computer-
assisted analysis with DENDRON, and the results
obtained conrmed the ndings obtained with SpeI-
gererated DNA proles (data not shown).
Replacement of suction hose connectors
with new-design connectors
The results of this study implicated the suction hose
connectors as the primary source of bacterial
contamination, and it is therefore likely that
seepage of liquid from the suction hoses led to
subsequent bacterial contamination and corrosion
of the DCU baseplates. These connectors with the
suction hoses attached are tted to the DCU by
pushing the connectors through machined holes in
the DCU baseplates into the hose-receiving orices
(Figures 1 and 2). Thus the connectors were prone
to loosening due to movement of the suction hoses
during clinical sessions. In an attempt to nd a
practical solution to this problem, a collaboration
was established with Planmeca Oy (Helsinki, Fin-
land), the manufacturers of the Prostyle Compact
DCUs used in Dublin Dental Hospital. Planmeca
engineers designed a new type of interlocking
connector system to secure the suction hoses to
the DCUs (Figure 4). The new system consists of
three components, including a new type of hose
connector, a metal bushing receiver for each
connector and a securing clip. New suction hoses
Figure 3 Dendrogram generated from the similarity
coefcients (S
AB
s) computed for every pairwise combi-
nation of SpeI-generated ngerprint proles of 41
Pseudomonas aeruginosa isolates recovered from three
separate sites in 19 dental chair units. The origins of the
isolates are shown in Table III. At an S
AB
value of 0.24
(short dashed vertical line), the isolates are divided into
two main populations. The rst main population contains
three distinct clades, corresponding to ngerprint groups
I (serotype O:10), VI (serotype O:14) and VII (serotype
O:14). The second main population contains four distinct
clades, corresponding to ngerprint groups II (serotype
O:10), III (serotype O:6), IV (serotype O:5/O:16) and V
(serotype O:11). The majority of the isolates tested
belonged to ngerprint group II (serotype O:10). A
number of clusters of indistinguishable isolates (average
S
AB
Z1) are evident within the ngerprint group II clade.
Two of these containing eight isolates and three isolates
are indicated by the notation a and b, respectively.
Despite the presence of clusters within the ngerprint
group II clade, all of the isolates within this clade were
very closely related (average S
AB
Z0.93). The provenance
of the isolates is shown in Table III. H, attachment end of
high-volume suction hose; B, DCU baseplate; C, coarse
lter cage housing. The serotypes and ngerprint groups
of the isolates are shown to the right of the dendrogram.
M.J. ODonnell et al. 356
were supplied, each tted with the new-design
plastic connector rmly attached to each hose.
These connectors interfaced with the metal bush-
ings tted through and extending below the suction
hose orices in the DCU baseplates, and were held
in place by the insertion of a plastic clip (Figure 4).
Each connector interfaces with a groove machined
into the receiving bushing and a watertight seal is
obtained by insertion of the securing clip. The
securing clip also prevents loosening of the suction
hoses caused by movement of the hoses during use.
As many of the baseplates in the DCUs in Dublin
Dental Hospital had moderate to severe corrosion
around the suction hose orices, it was necessary to
replace the baseplates with new baseplates prior to
tting the new suction hose connectors. The
original DCU baseplates were made of steel electro-
coated with paint on the outside to prevent
corrosion. However, the suction hose orices were
machined following electrocoating, with the result
that the internal circumference of the orices
themselves consisted of naked steel. To circumvent
any further potential problems of steel corrosion,
Planmeca advised replacement of the steel base-
plates with new aluminium baseplates because
aluminium is not as prone to corrosion as steel in
moist or wet conditions.
All 103 DCUs in Dublin Dental Hospital were
retrotted with new aluminium baseplates and with
the new-design suction hose connector system in
December 2000. No baseplate corrosion or damp-
ness at the suction hose attachment sites was
observed over a period of three years following the
changing of the DCU baseplates and hose connec-
tors. Furthermore, microbiological sampling of
baseplates adjacent to the suction hose-attach-
ment sites from 30 DCUs selected at random
revealed the complete absence of contamination
with Pseudomonas spp. and related species. Similar
results were obtained on three separate occasions
over a one-year period following tting of the new
baseplates. These results demonstrated that the
new-design suction hose connectors are an effec-
tive practical solution to the problem of seepage
from the suction hoses, and thus effectively prevent
further contamination of the DCU baseplates.
Discussion
Within six months of opening of the new Dublin
Dental Hospital in September 1998, areas of
corrosion became apparent on many of the base-
plates of the DCUs with which the hospital is
equipped. The corrosion was localized to the area
where the high- and low-volume suction system
hoses were attached to the main body of the DCUs.
Preliminary observations revealed that the areas of
corrosion were damp and harboured high concen-
trations of Pseudomonas spp. and related bacterial
species. The results of this study demonstrated that
this bacterial contamination was probably due to
leakage from the suction hoses because of poorly
designed suction hose connectors. It is very likely
that movement of the hoses during use in clinical
sessions eventually resulted in loosening of the
connectors from the receiving orices, causing
leakage of uid from the suction system (Figure
2). This problem was solved by replacing the
original suction hose connectors with newly
designed interlocking connector collars and bush-
ings that rmly retained the hoses within the hose
receiver orices so that they could not be loosened
by movement of the suction hoses during use
(Figure 4). This strategy effectively resolved the
problem of seepage of liquid from the suction
hoses, and eliminated further contamination of the
DCU baseplates.
In the present study, Pseudomonas spp. and
Figure 4 Components of the new-design interlocking suction hose connector system. (a) Dental chair unit (DCU)
baseplate tted with hose receiver bushings. (b) Suction hose tted with connector. This interfaces with one of the
bushings shown in (a). (c) Suction hose with connector interfaced with DCU baseplate bushing with securing clip in place.
Bacterial contamination of dental chair units 357
related species were used as marker organisms for
contamination of DCU baseplates and attachment-
end high-volume suction hoses, and similar organ-
isms were recovered fromboth sites. The connector
collars attached to the ends of the high-volume
suction hoses and the inside surfaces of the hoses
were all heavily coated with green/brown-coloured
biolm reecting the presence of pigmented
Pseudomonas spp. This evidence strongly suggested
that bacterial contamination of the DCU baseplates
originated from within the suction system. Inter-
estingly, the relative abundance of Pseudomonas
spp. and related bacterial species recovered from
the DCU baseplates and the attachment-end hoses
sampled differed. P. putida was the predominant
species recovered from the attachment-end high-
volume suction hoses, whereas P. aeruginosa was
the predominant species recovered from the base-
plates. These ndings may reect the local
environment present at each of the sites con-
cerned. Alternatively, P. aeruginosa may be better
suited to survival outside of the suction system (i.e.
on the baseplate surfaces) where the conditions are
drier.
Five different serotypes were found among 41
selected P. aeruginosa isolates recovered from DCU
baseplates, attachment-end high-volume suction
hoses and suction system lter cages from 19
separate DCUs (Table III). Fourteen of the 19 DCUs
yielded P. aeruginosa from two or three of the sites
tested, and isolates of the same serotype were
recovered from the different sites in the same DCU
in all cases. These ndings suggested that P.
aeruginosa isolates recovered from DCU baseplates
originated from other areas within the suction
system, and also indicated that only a small number
of P. aeruginosa strains had colonized the DCU
suction systems throughout the hospital. As the
discriminatory ability of serotyping is limited for
strain differentiation
19
and in order to investigate
the relatedness of the P. aeruginosa isolates in
more detail, the population of isolates was analysed
by DNA ngerprinting. DNA ngerprinting analysis of
SpeI-digested high-molecular-weight genomic DNA
of 28 selected serotype O:10 isolates revealed that
the isolates could be separated into two clearly
distinct ngerprint groups, termed groups I (four
isolates from three separate DCUs) and II (24
isolates from 10 separate DCUs), respectively.
Computer-assisted analysis of DNA ngerprint pro-
les revealed that group I and II isolates were
distantly related (Table IV and Figure 3). The four
group I isolates were indistinguishable by nger-
printing (S
AB
Z1.0) and all belonged to a single
strain, whereas some variability in ngerprinting
patterns was observed among the 24 group II
isolates. Nonetheless, group II isolates were very
closely related (average S
AB
Z0.93) and were
undoubtedly clonal. These results were conrmed
for a subset of eight ngerprint group I and group II
isolates by XbaI ngerprinting of genomic DNA.
Computer-assisted analysis of SpeI-generated P.
aeruginosa isolate proles showed that the 41
isolates of P. aeruginosa examined belonged to
seven separate strains, conrming the presence of a
small number of P. aeruginosa strains in the
hospitals DCU suction systems, one of which
(serotype O:10, SpeI ngerprint group II) predomi-
nated (68.3%). Why this latter P. aeruginosa strain
should have become predominant in the hospitals
DCU suction systems is not clear. Perhaps this strain
is particularly well adapted to survive in the DCU
suction systems. Alternatively, this strain may be
particularly resistant to disinfection. Prior to this
study, the suction system of each DCU was disin-
fected after each clinical session (i.e. twice daily,
MondayFriday) with the phenolic disinfectant Puli-
Jet (Cattani, Parma, Italy). During each disinfection
cycle, 1 L of disinfectant diluted to the appropriate
working concentration was aspirated through both
the low- and high-volume suction hoses by activat-
ing the suction system. Serotype O:10 isolates
appear to be relatively rare and a Russian study
reported a prevalence of only 1% among 708 P.
aeruginosa strains serotyped.
20
Interestingly, a
recent report described an outbreak of infection
caused by serotype O:10 P. aeruginosa isolates in a
neonatal intensive care unit in France associated
with a contaminated milk bank pasteurizer and
bottle warmer.
21
Fourteen cases of infection and 17
cases of gastrointestinal tract colonization were
recorded with four fatalities. In the present study,
the original source of the ngerprint group II strain,
and the other strains, is unknown. It is possible that
they originated from the DCU water supply,
although an in-depth study on dental unit output
water quality from this laboratory did not recover
P. aeruginosa during a prospective study of multiple
DCUs over a period of several months.
22
Alterna-
tively, the organisms may have originated from the
oral cavities of dental patients.
23
The results of this study demonstrated the
presence of high densities of Pseudomonas spp.
and related organisms within the suction system of
the DCUs used in Dublin Dental Hospital. P.
aeruginosa has frequently been recovered from
damp or moist environments in hospitals.
2426
These
sites often act as a focus for patient contamination
and infection. As mentioned above, the hospital
DCUs are disinfected twice daily by aspirating a
disinfectant solution through the suction hoses, a
process that takes approximately 1 min. This
M.J. ODonnell et al. 358
regular disinfection was evidently ineffective at
controlling bacterial contamination in the DCU
suction systems. The reasons for this are not
immediately clear but may be due to the fact that
bacteria present in biolm, especially Pseudomonas
spp., are more resistant to disinfectants than
planktonic organisms.
2729
Secondly, the very short
contact time that the disinfectant has with the
inside surfaces of the suction system (i.e. approxi-
mately 1 min) is likely to be a contributory factor.
As all DCU suction systems operate in an analogous
manner to a domestic vacuum cleaner in that
material, including disinfectants, is sucked rapidly
through the suction hoses to a central receptacle, it
is very likely that most DCU suction systems harbour
bacterial biolm due to inadequate disinfectant
contact time. In this regard, it is interesting to note
that ongoing studies in this laboratory with DCUs
outside Dublin Dental Hospital have documented
the presence of extensive biolm in the suction
systems of several brands of DCU other than
Planmeca units (D. Coleman, unpublished). Empiri-
cal studies with a range of disinfectants and
disinfection protocols need to be undertaken to
assess which is the most effective at eliminating
biolm from DCU suction systems and to determine
optimum disinfection conditions.
The presence of high densities of Pseudomonas
spp. and related organisms within the DCU suction
hoses despite regular disinfection is worrying. A
small number of studies have demonstrated that,
under certain conditions, liquid from the low-
volume suction line can enter a patients mouth
during use.
3032
This indicates that retraction of oral
uids and biolm-derived micro-organisms from
contaminated suction hoses could potentially be an
important source of cross-contamination and cross-
infection. It should be noted that the low-volume
suction hoses were not investigated in the present
study. However, studies from our laboratory
revealed that they were just as contaminated as
the high-volume hoses. There are virtually no
published reports on the extent of bacterial
contamination of, or biolm formation in, dental
unit suction systems. This potentially potent source
of cross-infection in the dental clinic needs to be
investigated further.
In the present study, Pseudomonas spp. and
related species were used as marker organisms for
DCU contamination. No attempt was made here to
determine the complete range of microbial species
present on DCU baseplates or suction system sites
as it was beyond the scope of this study. It is very
likely that a wide variety of other micro-organisms,
including human-derived pathogens and potential
pathogens, are present in DCU suction systems. Due
to the nature and function of the DCU suction
system, oral and blood-borne micro-organisms are
invariably aspirated through the system during use.
These micro-organisms include bacteria, yeasts,
fungi and viruses, the latter including human
immunodeciency virus, hepatitis B virus, Epstein-
Barr virus, cytomegalovirus and other herpes group
viruses.
33,34
While many of these organisms are
unlikely to survive for prolonged periods outside the
body and are unlikely to withstand drying, some,
such as hepatitis B, which can be present in large
numbers in saliva,
35
can survive for signicant
periods outside the body.
36
Studies are currently
in progress to comprehensively evaluate the variety
of microbial species present in DCU suction
systems.
The identication of the original hose connectors
as the primary cause of DCU baseplate contami-
nation and the implementation of an effective
practical solution to this problem by retrotting all
of the hospitals DCUs with the new-design hose
connectors efciently resolved the problem of
suction-hose-derived DCU baseplate contami-
nation. However, the results of this study highlight
the presence of extensive bacterial biolm in DCU
suction systems. This phenomenon needs to be
investigated in more detail.
Acknowledgements
This study was supported by Irish Health Research
Board grant RP07/2000 to D.C.C. We thank D.
Clarke and J. Swan for technical assistance in
installing the new suction hose connectors and
baseplates. We thank J.-P. Teravainen and T.
Flyktman from Planmeca Oy (Helsinki, Finland) for
developing and providing the new suction hose
connector system and for technical information and
advice. We thank Dr T.L. Pitt from the Central
Public Health Laboratory, Colindale, London, for
providing the P. aeruginosa O-specic antisera.
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