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# Take the Bite Out of Dental Amalgam Waste Breakout Group Recommendations

One of the key efforts of the April 2008 conference was a n interactive session to identify components of a model dental amalgam waste reduction program

. Breakout groups discussed fi ve topics. The groups reached the conclusions described below.

Outreach and Education

 A critical first step is meeting with dental societies. This action includes both meeting with officers and speaking to the general membership.

 Assembling a dental o ffice database requires a variety of resources. The most important resource is a local business directory, such as the Yellow Pages

. Additional resources include state licenses, plumbing or building inspections, and occupancy permits

. T he database will need constant maintenance because the dent al office population is dynamic.

 Time needs to be allowed for education to be absorbed and for multiple opportunities for the message to be shared. Being open to dialogue is important for assuaging skepticism, answering technical questions, and addressing unusual situations.

 To achieve long

- term change in the culture of dentistry, dental schools and technical schools need to establish an awareness of mercury issues and reduction strategies. Therefore, contac t with local dental and technical schools is strongly recommended. This contact includes both speaking to staff and speaking directly to students.

 A n initial survey to i dentify current practices i s valuable to establish a baseline for measuring progress.

Reduction Approach

 Programs should include both “carrots” and “sticks.” Factors affecting implementation include the administrative and fina ncial capacity of the public
agency; the size of the dental community ; the amount of private, state , or federal support available ; and existing local and state law.

 “Carrots” include awards recognizing positive action and subsidies for installing separators or recycling. Awards and subsidies are great for maintaining rapport and speeding progress. However, they will not work alone. In most communities, some degree of willful disregard or simple ignorance is likely to persist. For these offices, “sticks”, such as reporting rules and penalties, are
necessary.2

 The size of the community is a critical factor. Gene rally, the larger the community, the more formal the program needs to be. If a community is small enough that the public agency can reach every office i ndividually, then a less formal approach is m ore likely to be effective.

 P ublic agencies often have broad legal authority, making e xisting legal authority sufficient to take action in most cases

. This authority includes the authority to abate a public nuisance , to prevent pass

- through , or to require pollution prevention plans

. However, detailed new rul es would focus attention and f acilitate compliance. General r equirements , rather than individual control mechanisms, are likely to be sufficient because requirements will not change from place to place.

 The recommended criterion for being in cluded in t he source reduction program is whether the dental office conducts any placement or removal of amalgam. This criterion is simple and maximizes environmental protection.

 Finally, c ommunities should investigate opportunities to coordinat e amalgam work with other environmental or health programs. For example, amalgam management could be consolidated with work regarding lead foil

, X

- ray film development chemicals , radiation safety, or medical waste.

Separator Standards

 Generally, implementing the ISO stand ard is effective and efficient. Uniformity and certainty benefit the market. Requirements beyond the ISO standard require substantial effort for uncertain environmental benefits. If communities desire a standard more stringent than the ISO standard, the n they should consider using the lists that other communities

, such as King County, W ashington, have already developed.

 Certain ly, the ISO standard needs to be reviewed for opportunities for improvement . Also, the testing of devices by certification bo dies is valuable. However, these tasks are most appropriate when done on a national basis , rather than locally.

 Importantly, implementation of a device that meets the ISO standard is not the only relevant factor for ensuring good performance . Effort is also needed to ensure that devices are matched to appropriate circumstances. Dental supply companies are developing expertise in this area. However, this expertise is focused on protecting the dental practice, rather than maximizing environmental protect ion. Therefore, developing some capacity to review the appropriateness of installations would be valuable.3

 Finally, even if the separator is appropriate for the circumstances, it will not be effective unless it is maintained. Separator manufacturers a nd supplier s need to clearly articulate maintenance requirements

, dental offices need to m aintain the devices as indicated, and public agencies need to review the maintenance that is occurring. Just as with separator selection, some expertise regarding ap propriate maintenance would be valuable. Inspections and reports are techniques to obtain information regarding actual maintenance practices. Of course, some risk of adverse consequences, such as penalties, needs to be present for cases where maintenance is chronically poor.

Ensuring Compliance

 Reporting, certifications, and inspections each have important role s for ensuring good performance

. Considerations include: maintain ing an awareness of mercury issues among dental office staff ; the amount o f information needed by the public
agency to measur e progress ; the administrative burden for the public agency; and the administrative burden for dental offices.

 Generally, f

or showing the amounts of mercury waste recycled and the date of the shipments, annual reports are appropriate. This report would include

c ertifications indicat ing continuing implementation of best management practices and proper maintenance the amalgam separator , if one is installed . Inspections are necessary to verify the reporte d information and maintain familiarity with the dental community

. Inspections of each office should occur at least every two
years.

 For ensuring compliance, both initial and continuing training is critical. Therefore, public agencies need to work with c ontinuing education providers to ensure coverage of mercury issues.

 Sampling dental office discharges is not recommended, except in cases of unusual problems.

 One aspect of ensuring compliance is being aware of changes to dental office locations over t ime. To track dental offices as they open, close, and move,

m onitoring occupancy permits and business directories should occur

.

Evaluating Progress

 Knowing initial conditions is important for evaluating progress. These initial conditions include both dental office practices and influent, effluent, and b iosolids concentrations. Over time, collecting data regarding these parameters on r egular schedule is necessary.4

 Influent and effluent concentrations are likely to decrease slowly. Therefore, public a gencies need to be prepared to t rack data over a long time

.

 Tracking the total mass or volume of mercury being shipped from dental offices for recycling is valuable. However, obtaining timely and uniform data will be challenging.

 Tracking t he amount o f mercury being collected would be optimum, but obtaining the mass of mercury in every shipment of mercury waste is likely to be impractical.

 Sewer cleaning and rehabilitation may release mercury accumulated over long periods. These temporary loads of me rcury complicate evaluating long

- term trends. Therefore, being aware of cleaning and rehabilitation projects is important for understanding these trends.

 As with other topics, m aintain ing an accurate list of current dental offices is important, along wit h information showing their current compliance status.