Many dental offices manage waterlines blindfolded: dump in treatment products, test sporadically, and hope for compliance. But waterline safety isn’t just a clinical detail—it’s a litmus test for leadership. Reliable waterline testing reveals more than bacteria counts; it exposes the strength of a practice’s discipline, accountability, and patient-first values. In an era where a single outbreak can shatter brand equity, erode investor confidence, and damage leadership credibility, treating waterline testing as a core key performance indicator (KPI) separates the organizations that scramble from those that lead.
Some argue the cost of compliance outweighs the risk of penalties. But that perspective collapses when you factor in the true cost of reputational damage and litigation. In 2016, one pediatric dental group learned this the hard way after an outbreak linked to contaminated waterlines resulted in 71 confirmed infections, 49 probable cases, and more than 200 lawsuits— an incident estimated to cost tens of millions.
But it doesn’t have to be this way.
There are large DSOs hitting waterline compliance rates well above 95%. That’s not luck. It’s the result of empirically driven, well-built water management protocols that allow waterline testing to shift from a reactive headache to a strategic KPI. High pass rates aren’t just about ticking regulatory boxes; they offer a window into the health of the entire operation.
When DSOs start proactively treating waterline testing as a KPI, they unlock powerful insights into their training effectiveness, operational discipline, and compliance culture at a team and organizational level.
Treatment Isn’t Enough— Test or Risk It
While roughly 75% of offices actively treat their waterlines, fewer than 25% test them. That’s a dangerous disconnect. Regulations require meeting a 500 CFU/mL bacterial threshold. Treatment alone isn’t a guarantee; without testing, there’s no way to confirm the treatment worked.
“Laws and regulations are created because the mass population is not following best practices and guidelines. Those who understand testing is doing the right thing for the patients are the early adopters, starting processes long before they are forced,” Kendra Flowers, a clinical operations/ compliance leader, says.
it’s a competitive advantage.”
Many waterline test failures come down to simple, preventable oversight, like forgetting to add a treatment tablet or neglecting in-line filters on ultrasonic scalers. These small gaps often fly under the radar until a failed test forces attention.
Water quality KPIs should be treated like spore testing: nonnegotiable and high stakes. “Unsafe water has deadly consequences,” Flowers says.
The key? Integrate waterline data into dashboards, reviews, and incentive programs. What gets measured—and rewarded—gets done.
Training That Shows Up in Every Test Result
Waterline test results don’t just measure bacteria—they measure training. When pass rates are consistently high across locations, it’s a strong signal that teams are intentionally following protocols.
According to Flowers, high failure rates are common during the initial implementation of a dental waterline protocol. The failure rates reflect the lack of standardized processes, such as:
- Heavily occluded lines requiring replacement
- Elevated bacterial levels from municipal sources
- Staff unfamiliar with proper procedures
Over time, as the protocol becomes embedded in daily operations, staff gain greater awareness, adopt best practices to prevent failures, and consistently follow maintenance routines.
“Protocol makes or breaks waterline safety. We’ve tested hundreds of thousands of samples, and the truth is simple. Every product can work, and every product can fail if protocols slip. With the right training and sitespecific procedures, the majority of failures never have to happen,” says Brianna Niederschulte, President of Agenics Labs.
In short, high scores are proof that the training stuck. Use top-performing offices as a blueprint and treat low pass rates as flashing signs for retraining or standard operating procedure (SOP) overhauls.
Onboarding Passes the Ultimate Test
Waterline test results also serve as a real-time gauge of new hire readiness. When DSOs walk every new hire through SOPs in detail from day one, they sharpen accountability and drive better results. If waterline scores dip after onboarding, it’s time to tighten the process—and make sure new hires aren’t just trained but battle-ready.
To assist in new hire readiness and better results, Agenics Labs provides customized onboarding and training for DSOs, including developing and maintaining SOPs.
“Not only does this allow us to provide DSOs with solutions we know will work, but it also means we can work right alongside their practices, helping staff adhere to the group’s established procedures,” says Niederschulte.
Celebrate Your Champions
When offices proactively test and maintain waterlines without reminders, it reveals a culture of discipline and pride in clinical excellence.
“I like to identify champions in all areas of focus or initiatives I oversee,” Flowers explains. “Showcasing the team’s best practices, whether through a company newsletter, peer training for new offices, or coaching support for underperforming teams, not only drives broader adoption of effective strategies but also fosters the development of future leaders within the organization.”
Average DSOs comply because they have to, while great DSOs embed infection control into their operations because giving their patients the greatest care possible is their standard. Recognize and reward the teams that use best practices. Then, use their success to inspire others and embed a culture where accountability isn’t just expected. It’s celebrated.
A Hidden Indicator of Employee Burnout
If well-trained teams are still failing waterline tests, it’s often a red flag for deeper operational issues like understaffing, burnout, or lack of support. This reflects breakdowns in communication, resources, or trust between staff and leadership.
“Most issues turn out to be workflow inefficiencies requiring coaching or protocol tweaks. But when real resource gaps arise, it’s critical to escalate and engage leadership to find solutions,” Flowers emphasizes.
Use low pass rates as a trigger to reassess staffing, redistribute duties, and provide targeted support before small cracks become big problems.
Compliance as a Strategy, Not a Scramble
By adopting the most rigorous, yet reasonable, waterline testing protocols across all states, organizations can create a consistent standard of care and sustainable compliance culture.
“This approach not only mitigates risk but also positions the organization ahead of regulatory changes, ensuring readiness and reinforcing our commitment to patient safety and compliance,” Flowers says.
But protocols alone don’t cut it.
“For any system to succeed, it must be fully integrated into daily workflows, routinely measured, and supported by clear accountability,” Flowers adds.
That’s where deeper, more informative testing can make the difference. Equipping teams with the knowledge to understand what their results mean allows them to take ownership of the process.
“Our mail-in tests include additional water quality metrics that not only help us understand why a sample may have failed but also empower dental team members to identify their own protocol gaps. We are the only lab in the industry to include these extended metrics in every mail-in test, demonstrating our commitment to being comprehensive—one of our core values,” Niederschulte says.
Without this level of integration and insight, compliance becomes a scramble, not a strategy. The best DSOs embed waterline management into the daily routine, track it relentlessly, and use detailed data to prevent failures before they happen.
Benchmarking That Drives Results
Waterline compliance data isn’t just numbers. It’s a spotlight on which offices are excelling and which need help. By centralizing test results, DSOs can benchmark performance (and check compliance culture) across locations, identify top performers, and replicate their success.
“In addition to our online reporting hub, we curate customized reporting for DSOs, allowing them to view their test data in a variety of ways that can be leveraged for insights into their different locations and collective performance as an organization,” Niederschulte says.
The best teams pass on the first try, no hand-holding required. Their secret? Simple, consistent habits like daily maintenance logs, visual checklists, and operatory signage.
When shared through coaching, newsletters, or onboarding, these practices fuel a culture of compliance and improvement. This isn’t just about tracking—it’s about setting the pace.
Lead the Charge or Get Left Behind
When waterline safety becomes a core KPI, DSOs don’t just check boxes. They drive real, measurable excellence.
“Two factors consistently drive reliable waterline outcomes: first, standardized protocols tailored to the organization and second, ensuring teams understand the why behind waterline management through meaningful education. When both are in place, we routinely see offices jump from the industry average of around 70% pass rates to exceeding 95%,” Niederschulte explains.
Waterline safety isn’t a checkbox—it’s a competitive advantage. For DSOs, every test is more than a compliance measure; it’s proof of operational discipline, staff readiness, and patient-centric leadership.
The groups that test, not just treat, demonstrate to patients, regulators, and investors that the put safety and accountability first. Those are the DSOs that will earn trust, scale with confidence, and lead the industry forward. The challenge is simple: Use waterline testing as your gauge. It won’t just tell you if your water is safe—it will tell you if your organization is built to win.
Sources:
Ross, Erin. “Infection Outbreak Shines Light on Water Risks at Dentists Offices.” NPR, Average Top-Performing DSOs September 30, 2016.
