In accordance with the Health Technical Memorandum (HTM01-05), dental practices ought to engage an external specialist to aid in fulfilling the recommendations outlined in Section 3 of the guidance for dental unit water lines. This necessity arises from the expertise demanded in this specialised field, as well as the need for specialist knowledge of Legionella and other waterborne organisms. Although dental practices might be capable of carrying out some control measures for dental unit water lines themselves, such as routine flushing and disinfection, it is advisable that they employ an external specialist to perform the risk assessment and provide guidance on suitable control measures. To summarise, dental practices should engage an external specialist to carry out the risk assessment and offer advice on appropriate control measures for dental unit water lines and domestic hot and cold water systems, due to the expertise needed in this specialised field. It is crucial that the individual conducting the risk assessment is trained and competent to do so.

Dental practices, like all businesses, have a moral and legal requirement to ensure the safety of their employees and the public. A legionella risk assessment helps identify potential risks associated with the water system in a dental practice, including the potential for Legionnaires' disease to be contracted by patients or staff. The Health and Safety Executive's Approved Code of Practice (ACOP) L8, as well as the HSE guidance documents HSG 274 Parts 2 and 3, Health Technical Memorandum HTM 04-01, and HTM 01-05, all require businesses to carry out a risk assessment that identifies all foreseeable risks associated with their water system. The risk assessment must include all water systems and dental equipment, including dental lines, ultrasonic scalers, cavitrons, airflows, air purifiers, and any other equipment that may create aerosols or that water flows through. Failure to conduct a legionella risk assessment in a dental practice can result in legal action and serious harm to patients or staff.

The frequency of reviewing the legionella risk assessment in a dental practice depends on a number of factors, including the condition of the practice water system, management system, and other factors. The risk assessment should be reviewed regularly enough to keep it up to date and ensure that control measures remain effective. Dental practices should refer to their competent person risk assessment, which should clearly advise when the risk assessment should be reviewed. It is important to note that the risk assessment should not only be reviewed when the dental practice receives a call from the CQC. According to the Health and Safety Executive's Approved Code of Practice (ACOP L8), the risk assessment is a living document that must be reviewed regularly and specifically whenever there is reason to suspect it is no longer valid. This may result from changes to the water system or its use, changes to the building in which the water system is installed, the availability of new information about risks or control measures, the results of checks indicating that control measures are no longer effective, changes to key personnel, or a case of legionnaires’ disease/legionellosis associated with the system. In summary, dental practices should ensure that they have a competent person risk assessment in place, which clearly advises when the risk assessment should be reviewed. They should also be aware of the factors that may require a review of the risk assessment, and ensure that the assessment is revised immediately when necessary to protect the health and safety of their patients and staff, rather than waiting for a call from the CQC.

In line with the HTM guidance for dental practices, the registered manager is considered to be a responsible person. As part of their role, they should attend suitable training to ensure that they have the necessary knowledge and skills to carry out their responsibilities effectively. Basic awareness training is not considered to be adequate for someone who is nominated as a responsible person or their deputy. Instead, more comprehensive and in-depth training should be pursued to equip them with the expertise needed to maintain a safe and compliant environment within the dental practice.

A written scheme of control for dental practices is a document that outlines how the practice will manage and control the risks associated with legionella and other bacteria in its water systems. The CQC expects all dental practices to have a site-specific written scheme of control in place to ensure compliance with legal requirements and ensure patient safety. All of our legionella compliance packs for dental practices include a site-specific written scheme of control draft and bespoke record keeping system for their practice. CQC Dental Mythbuster 5: Legionella and dental waterline management https://www.cqc.org.uk/guidance-providers/dentists/dental-mythbuster-5-legionella-dental-waterline-management

The checks required for each dental practice will vary depending on the specific water systems present in the practice. However, standard checks may include weekly flushing of infrequently used water services, monthly temperature monitoring of hot and cold water outlets, and quarterly cleaning of showerheads. These checks are intended to prevent the growth of legionella bacteria by ensuring that water is not allowed to stagnate and that temperatures are kept at safe levels. It is important to note that these checks are not exhaustive, and there may be other checks that are necessary depending on the specific water system in a dental practice. For this reason, it is important for dental practices to refer to their site-specific legionella risk assessment, which should identify all water systems present in the practice and set out the control measures required to manage the risk of legionella.

The Health Technical Memorandum (HTM 01-05) guidance does not advocate the routine use of dip slides. Instead, dental practices should have a system in place to manage the level of microbiological activity in their dental unit waterlines. This system should include a mixture of control measures, such as regular and proactive disinfection of the dental unit waterlines, flushing of lines to prevent water stagnation and biofilm formation, and other measures outlined in HTM 01-05. It is important to note that the product used for routine disinfection of dental unit waterlines MUST be approved by the chair manufacturer (for example, Belmont, Kavo, A-dec, Stern Webber). Using a product that is not approved by the manufacturer may invalidate the warranty and could potentially damage the dental unit. Therefore, it is essential to ensure that only approved products are used for routine disinfection. If you decide to deviate from the advice provided by HTM 01-05 and the chair manufacturer, you should prove that the control measures you have adopted are effective. Regular sampling could be used to demonstrate that control is in place. Although many suppliers advocate using dipslides or HPC samplers, HTM considers those methods unreliable and advises that UKAS-accredited methods of testing, such as TVC sampling, should be used. Microbiological sampling may provide some useful information about water quality, but the data is limited to the specific date and time when the sample was collected. Rather than relying solely on testing, proactive periodic disinfection should be used to maintain water quality.

Routine water sampling for legionella is not usually required in a dental practice, unless there is doubt about the efficacy of the control regime or it is known that recommended temperatures, disinfectant concentrations, or other precautions are not being consistently achieved throughout the system. Sampling may be appropriate in certain circumstances, such as when water systems are treated with biocides or in high-risk areas. If sampling is carried out, it should be in accordance with BS 7592.