OW-2003-0074 EPA DOCKET SECTION 2.2.2 DCN 00144 10/07/1998


# A New Prescription: Pollution Prevention Strategies for the Health Care Industry
Wednesday October 7, 

### 1998 Boston University Corporate Education Center Tyngsborough, Massachusetts 

# Proceedings

Section 

### 4: Dental Facilities

Section 

### 4:Dental Facilities Cynthia Welland Balogh and 

### Dr. Paul Rubin, Removal of Mercury from DentalAmalgam Wastewater PaAicia White, Dental Office Waste Management: Safeq and regulatory ComplianceIssues 2
31

1Cynthia Welland BaIogh King County Local Hazardous Waste Mhagement Program Seattle, Washington Paul G. Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington


### Removal ofMercury from Dental Amalgam Wastewater
Abstract Dentists, when either placing new or removing old "silver" fillings generate a considerable amount of waste amalgam. This may be in the form of chunks, small grindings, or 

### slurry of fine grindings water. Most of this is vacuumed from the patients' mouths and eventually sent down the drain into the office wastewater. Municipalities, including King County, have found that a significantpercentage ofmercury discharged to the sewer systems originates from dental office effluent. This amalgam wastewater exceeds King County sewer discharge limitations for mercury by three to four orders of magnitude. Technological source control solutions do exist and are availableto dental offices. However, there are concerns about the effectiveness, ease ofuse and cost ofthese devices. Overcoming these and otherbarriers are essential to creating new pollution prevention behaviors that keep dental mercury from the municipal waste streams and reroutes it to reclamation.
This paper evaluates these concerns from the viewpoint ofboth local government technical assistance providers and a practicing dentist. Practical aspects of choosing to remove and reclaim mercury as well as selecting and using these devices will be presented.
Devices availableto dentists range in their effectivenessand cost. This paper evaluates methods of treating dental wastewater to separate amalgamparticulate from the liquid fraction of the wastewater. The metals removal capacity of commercially availableequipment from two manufacturerswas investigated. We also designed, built and demonstrated metals removal capacity of 

### a simple, inexpensive settling system. In addition to technological issues, behavior change principles are being applied to outreach efforts. Data from this study are being used to help determinebest management practices for dental amalgam wastewater. All three pieces of equipmenttested show one to four orders ofmagnitude decrease in mercury concentration and loading after treatment. Removal rates average 95-99% depending on equipmentused. 

### In the case of the commercial equipment, our data verifies manufacturer's claims for removal rates 

### of around 

### 99%. For our own piece of equipment,we see that a simple, inexpensive settling chamber can achieve removal rates in the 90-95%range and retain that ability over an eight month testing period.



### 2Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G.Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington

Some of the criteria for evaluating the suitability of a system include: effectiveness, simplicity of operation and design, level of handling of waste material required of officepersonnel, "'fail-safe" mechanisms designed to avoid accidental spillage, system for handling proper recycling 

### of material, and cost. While not all barriers to preventing mercury pollutionhave been over come, we have begun to address major concerns. Systems are in place in King County for proper collecting,transporting and recycling the mercury waste. Mercury removal from amalgam wastewater is recommended before discharge to the King County Metro sewerage system. We are seekingvoluntary compliance from the dental community. Introduction
In the past twenty-five years, sewer utility pretreatment programs have successfully addressed discharge from large generators, (significant industrial users 

### -- SIUs), to the sewer system. These industries are regulated, permitted and monitored. Currently about 15% of the pollutants to the sewer can be attributed to the big generators. The remaining 85% is from households, small businesses (conditionally exempt small quantity generators CESQGs), and non-point sources, such as stormwater(Galvin, 1991). Programs, such as King County Local Hazardous Waste Management Program in Washington State, have been developed to address the household and small business hazardous wastestream. Like other pollution prevention and source control programs, our purpose is to assure reduction of hazardous materials going into the municipal wastestream, to reduce the hazardous materials discharged to the environment through landfills, and sewage effluent and biosolids. Whether biosolids go into land application,as in King County, or are incinerated, source control is necessary to prevent hazardous material from accumulating and dispersing through the soil, water or air. This program works with many industry types to develop best managementpractices, provide on site consultations and assistbusinesses in reducing hazardous waste. In additionto the dental profession, some of these are print shops, photo processors, automotive repair, auto-body shops, 

### dry cleaners,machine shops and marinas. Why Dental Waste? Why were we concerned with dentists? Initially,King County was required by Washington Department ofEcology to prioritize the elimination of occasional spikes in the concentrationof mercury going to King County's two main treatment plants. Other considerations were the presence ofmetals, such as mercury and silver, in wastewater treatment byproducts, including biosolids for agricultural use and effluent for non-potable water reuse programs. Source control of contaminants

## -- preventing metals and otherpossible pollutants from entering the sanitary sewer system in the 

### fKst place 

## - is a priority in US Environment Protection Agency, Washington 3Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington
Departmentof Ecology and King County policies (The federal Clean Water Act; Washington State Water Pollution Control Law; Washington State Hazardous Waste Reduction Act; King County OrdinanceNo. 

### 11034). Thermometers, barometers, switches, fluorescent tubes, mercury boilers, manufacture of mirrors, dental amalgams, latex paint, pesticides and the electrical and instrument industries are among the potential sources of mercury (The Merck Index, 1989). In the King County service area there were no permitted significantindustrial users (SIUs) generating significant levels ofmercury. Industrial laundries, which may use limited amounts of mercury as a biocide, are regulated through pretreatmentpermits. All permitted discharges are restricted to a mercury limit of .2 parts per million. Mercury as a biocide 

### in paints has been largely phased out and a review of studies on potential household product contributionsdid not indicate significant sources of mercury from this sector (Galvin, 1991; Rourke, 1991;Dickey, 1990-91;Jenkins and Russell, 1990; and Gurnham et al., 1979). Of the remaining sources, dental offices appeared to be the most likely potential source of mercury in the publicly owned treatmentworks.
Of the several hazardouswastestreams discharged from dental offices, we have focused this paper on amalgam wastewater, and, in particular, mercury. Although the other metals are of concern, mercury is present in the highest concentrations, is most toxic and has the lowest discharge limits (in King County). Mercury Cycle In Dentistry
How does mercury from dental amalgam actually get into the environment? The dental industry consumes perhaps 100T of Hg annually, though that figure 

### is diminishing. It's made into amalgam in the dental office. Then a number of things can happen that lead to it entering the environment [Figure 

### 11. Excess mixed amalgam that is not actually used in a filling or is carved away should be saved and recycledby the dentist. Some,perhaps, ignore this, and it ends up in the trash and eventually a landfill or incinerator. Hopefully that doesn't happen very often. Extracted teeth with amalgam fillings in them end up in trash or medicalwaste 

# - again, landfill or incineration. Crematoria have been shown to produce a significantamount ofmercury vapor from incineratedremains. But the most significant avenue that we're talking about at this conferencehappens when amalgam fillings are placed or removed and particles, chunks, dust, or slurry get vacuumed up by the chairsidedental vacuum system. Bigger chunks are caught in a chairside trap, and presumably this trap gets periodicallycleaned out and the pieces saved and Iater recycled. Any ofyou who are dentists know, however, that the dental staff often may take the easy way and simply throw this in the trash or wash it out in the sink 

## - down the drain. Most ofwhat is vacuumed up is in smaller particles or 

### slurry, which passes right through the chairside traps and heads for the office wastestream. This is the part we're particularly interested in today. How much is it, really, and how can it be stopped?

4Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington
Figwe 1. Dental Amalgam Wastestream Schematic

5Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington

How Much Mercury? In 1990, when we began this project, very little was known about dental waste. 

### To appropriately address this waste, we needed to quantify and characterize it. We sampled the wastewater leaving the dental chair, and surveyed dentists to help determine quantities and types of wastes. Dental amalgam is made up of about 40-50% mercury, 25% silver and the rest is copper, zinc and tin. The results of sampling and surveying showed mercury concentrationsof 100-2000 mg/L. The two long lines on the left side ofthe graph show the mean and standard deviation ofmercury in untreated wastewater from dental operatories. [Figure2.1 This exceeds our 0.2 mg/L local mercury limit by 

### 500 to 10,000times. The portion of the mercury to the King County sewerage system from dentists was conservatively calculatedat about 

### 14% or 

### 52 pounds per year. (Welland, 1991)
Other sewer districts have done similar studies. Minneapolis St. Paul found that an even greater proportion of mercury to the treatment plants, 76-80%, is from dentists. (Berglund, 1998). Differences in these results may stem fi-omsuch factors as other sources ofmercury, slightly different sampling methods, variability of samples, analytical diffrculties and quite conservative assumptionson our part.

6Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Acadaemy of Oral Medicine and Toxicology Seattle, Washington

Figure 2 Mercury 

### in Dental Wastewater Loading 

### to Sewer in mg/day



## 1025

975 925 875 825 775 725 675 625 575 525 475 425 375 325 275 225 175 125

75 25 --

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--

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### UNTREATED Samples 

## Treated Samples



## I1006 

# J

I575

n = 10 

# 1 Mean and one standard deviation indicated 

### Mean 

### +/- Standard Deviation Centrifuge I= .37 

### +/- 

## .3(n 

### = 13) 

### Centrifuge 2= .81 

### +/- 1.1 

### (n = IO) 

### Settling/Filter= 

### -31 +/- 

## .35(n 

### = 8) 

### Composited from 30 

### samples 

## l7G" Simple Settling= 25 

### +/- 19 

### (n 

### = 3)

' 

## 415

TREATED



## -25 Office 1 

### Ofice 2 Centrif 

### 1 Centrif2 SetlFilt Simple 

### % Remova 199.9 99.8 99.9 96Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington


### Approach Cooperation
From the beginning of this project we have worked with the local dental community. In 1990, we established an advisoryboard to explore dental waste issues and to help with a characterization study. We have continued with manyjoint meetings, waste management articles in the dentaljournal, talks and paper co-presented andjoint development of best management practices (BMP’s). Cooperation on waste management issues and outreach have been key. Voluntary Comdiance versus Formal Rulemaking
A local Hazardous Waste Disposal Rule for Dentistswas proposed in October 

### 1994. This rule would have required all area dentists who discharge to the King County POTW to install amalgam wastewater pretreatmentunits. During the public comment period the local dental community articulated their concern about further regulation of dental office waste disposal practices? citing such issues as costs, newly developing products and services, and unsubstantiated environmental damage. In addition,the local dental community expressed a willingness to work voluntarily toward reduction of their contribution ofhazardous substancesto the waste stream.
Instead of promulgating a rule for dentists,King County developed a program for working cooperatively with the dental community. compliance, based on the expectationthat this voluntary approach continues to be embraced by the local dental community and our agency. King County has three long-term goals for



### * First, institutionalizationof waste management and reduction techniques in all dental practices, includingreclamation of mercury and silver resources from amalgam wastes and 

### xray fixer. Second, the inclusion of information about dental waste management and reduction in all formal training programs for dental professionals in this geographic area. Third, to document a measurable decreasein the amount of metals dischargedto the sewer system from dental offices in King County. 

### * *

!Ling County and the Seattle-King County Dental Society have established an open, responsive and reasonable working relationship that has contributed to the success thus far of this voluntary approach to waste management 

### by dental offices in our area. Although interest is increasing, voluntary compliancehas been slow. Approximately 

### 1% of King County’s 1500 dentistshave installed amalgam separationdevices.Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington
Overcoming Obstacles
We have encountered many obstacles or barriers while moving toward better managementof wastes fi-omdental offices. We have also seen a tremendous increasein interest and solutionsto difficult issues. Issues include perception of problem, costs, technology and service availability. Acknowledging there is problem depends on having reliable information about the waste and about regulations. It also depends on being ready to address the problem areas. Characterizing dental waste showed both agencies and dentists how much mercury is in dental amalgam wastewater. Althoughphilosophical approachesto protection ofthe environment vary, and questions have been posed about what environmental damage is being done, a great many dentists are concerned about our environment and about doing what's right. The realization is growing that region by region, sectorby sector, everyone is being called on to eliminate or reduce hazardous wastes. It is this attitude, that we all have a part to play, and the desire to be part of the solution, that overcomes the perception, common to every regulated business, of being over regulated, ofbeing picked upon. Although some dentists may personally have no problem dischargingamalgam waste, many are recognizing the problem and want to individually,and as a profession, demonstrate a pro-activeresponse. Responsible hazardouswaste managementis being noticed. A King County recognition program, EnviroStars, provides recognition to businesses for their efforts to protect the environment. Currently, 36 dentists have been recognized as EnviroStars. In addition, Dr. Rubin has received a Washington State Governor's Award, the first dentist to ever do so.
costs Complaints about cost ofproper disposal are fiequent since incorrect disposal of waste to the sewer may have no initial direct cost to the discharger. Proper disposal may cost more up front, but reduces liability and, as we all become more aware of total cost accounting, we realize the future costs of today's behavior.
Pollutionprevention is based on 

### a hierarchy of eliminating, reducing, reusing or recycling wastes. Preventing pollution is very cost effective. The next step is source control. Once a pollutant has been generated, controllingit as close to its source as possible is generally the most effective and cost effective way of managing it. Once we accept that proper waste management and disposal are necessary, the task is to make it as convenient and cost effective as possible. Our program has taken a multi level approach to help dentists control costs. We valuated existing amalgam separation technology,developed inexpensive, effectivetechnology, encourage the development ofmore technological options, stimulate the vendors to provide convenient waste management services at a realistic cost,provide informationand free onsite consultations,modify regulationsto provide more flexibility,and provide incentives -vouchers up 50% 

### or $500 

### for services or equipment,to reduce hazardous waste.Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington 1. Paul G.Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington

Technolow
To evaluate methods of separating amalgamparticulate from liquid wastewater, King County tested the mercury removal capacity of two commercially available separator units and one easily fabricated settling unit. The tests were performed in dental offices. Manufacturers’ claims of 99 

## + percent removal during standard testing were compared to results obtained in operating dental offices under local conditions. Testingwas conducted for filtration, settling, filtration and settling, and centrifugation amalgam wastewater treatment equipment. The goal of testing the amalgam wastewater treatment units was to find out if treated amalgamwastewatermet King County’slocal sewer discharge limit of 0.2 milligrams per litertotal mercury. All operatories in this study used vacuum-suctiononly rather than cuspidor systems, reflecting the practice ofthe majority of dental offices in this region.
Results from the three amalgamwastewater treatment units are shown in Figure 2. The four points on the right side of the graph represent treated wastewater and show remarkable removal rates. All values are expressed in mercury loading (milligramsmercury per day). The loading figures show the weight of mercury dischargedper day, independent of water dilution, disinfectantsor any other materials.
The three tested units are shown on the graph as follows: mechanical centrifuge (centrif 1 and centrif

### 2), settling/filtrationunit (sethilt) and a simple, fabricated gravity-settling unit (simple) designedby a King County chemist and a process engineer - see Appendix 6). The graph shows one to four orders of magnitude reduction in mercury after treatment of amalgam wastewater. Significant reductions of mercury in the sewer discharged waste stream of dentists are achievable. The commercial equipmentreduced mercury by 99.9%. Even very basic treatment, such as that provided by the “homemade” King County model (less than $100 per unit), removed at least 95 percent of the mercury from rinse waters. While 

### high levels of reduction are feasible with treatment, it was not demonstrated that 0.2 ppm mercury couldbe consistently achieved with the equipmenttested. Chemicaltreatment in addition to physical amalgam removal did produce wastewater with a mercury concentrationof less than 

### 0.2 ppm. (Tomchick, 1998).Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington
Demonstration Testing for Vendors of Amalgam Wastewater Treatment Units Dentists requested some sort oftreatment equipment “approval”by King County to assist them in assessing amalgam wastewater treatment units. While King County does not recommend specific equipment, a testing protocol was developed in 1995to demonstrate whether a system consistentlyremoves at least 90 percent of mercury under typical conditionsthat include,but were not limited to the standardpractice use of in-line amalgam screens and traps. Demonstrations included installing the unit in representative dental offices. Requirementsfor the sampling’report also included the vacuum drop associated with the amalgam wastewater treatment unit - stated both objectively (inches of 

### Hg via gauge) and subjectivelyby dental office personnel. In addition, the reclamation or disposal of collected sludge and the method of infection controlhad to be explained. Finally, 

### a descriptionof the attentionrequired by the vendor or dentist for proper operation and maintenance of the unit had to be provided [see appendices 3 and 

### 4.1 Service A major gap in the amalgam management issue was the question ofreclamation. In 1990,the county had only one hazardous waste drop-off option that was available once a month for a fee of about $30 per gallon. It requires self-transportation, and has only one location. The material was handled as hazardous waste, and not reclaimed. Reclamation of amalgam slq required more preparation than solid amalgam particles. Shippingto distantreclaimers had limitationsas well. Also dentistsreally wanted a pick-up service, preferably of all wastes 

### -- hazardous and biomedical. Currently there are more services available, several mail-in servicesfor solid amalgam exist, one pick-up service, and amalgam separator companies usually provide reclamation service 

### as well. In a further effort to stimulatethe local market and initiate new waste management habits of dental clinics, King County and the local dental society are sponsoring a dental waste pickup project which must include amalgam waste. Vendors are encouraged to provide pick-up for multiple waste streams and dentists are encouraged to use these services regularly. The county pays for the firstpick-up. Three vendors have expressed interest, and the dental society will do the promotion and register dentists. King County will collect follow up information about the effectivenessofthe project.
What Makes A 

### Good System?
Let’s look at this diagram again [Figure 11. It looks like it ought to be fairly simple to trap this stuff- Well, it is and it isn’t. You can’tjust stuff some kind of filter in the line somewhereand have it work successfully. I’d like to point out some of the difficulties. Although there’s not aCynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington

lot ofvolume of water flowing through, it is flowing at a high rate of speed and force, mixed with large quantities of air. The speed and force are such that a simple filter is not likely to capture very much. Or, if the filter were dense enough to trap the sludgematerial, it would reduce the suction power 

### so much at the chairside that it would be unacceptable. Besides the technical difficulties in designing an effective system, there are also behavioral factors. Since dentists are not yet very sold on this problem or highly motivated to make changes, anything that interferes with their routine or diminishes the effective use oftheir existingequipment will meet strong resistance. Most designsnow incorporate some means of slowing down the flow to a trickle that can be effectively filtered, without diminishingthe suction power. This is usually accomplished with some type of aidwater separator tank. The vacuum pump is allowed to pull at the same force. The liquid portion of the evacuant drops into a holding tank or containerwhere it can then drain or settle through 

### a filter. The air whooshing through the line is vented to the outside of the building. This is required by code in any newer offices. It should be pointed out that this air contains a significantamount of mercury vapor, as demonstrated in a paper published a couple of years ago (Rubin, 1996, see appendix 

### 2). That’s a whole other issue, and we’re not addressing that in today’s presentation. At this point, most designs incorporate a filtration or settling process, or a combination. A couple of companieshave tried using a centrifuge design to separate the heavier metals from the liquid. Here is an example of one system that uses aidwater separation and a filtration system. Theie are a lot of companieswho have put a lot of effort into designing systems that will do the trick. Having seen most of them, tested several of them in my own office, and worked with these systems for the last eight or nine years, 

### I have learned a lot about what works, what doesn’t and why. I’d like to list for you what I feel are essential elements of an ideal mercury capturing system for 

### a dental office or clinic.
1. The system should be effective. That’s the whole point of this. It shouldbe able to prove that it can remove 90-99% of all the mercury, regardless ofparticle sizes in the amalgam sludge. At least two municipalities, 

### King County in Washington State, and Minneapolis have tested several companieswho have been willing to put their products through some testing protocols. It does matter how the testing is done. These two municipalities have done a great job, and 

### I think their results should be looked at more cIosely than what the manufacturers’ claim.


### 2. There shouldbe 

### no compromise in suction power. If youjust cram some kind of dense filter inline with the vacuum pump, the effectiveness ofthe vacuum at chairside is going to drop, as 

### I have mentioned. Again, this would be 

### an unacceptable compromise. 3. “Hands-Off” feature. If this material is toxic and nasty (which it is), it’s not a good idea to have a system where the dentist or staffhas to frequently empty containers,decant off liquids, or handle or change filters. Ideally a systemjust sitsthere and does itsjob without much hss or handlingby the staff. Again, if it’s difficult, the staffeventually won’t do it, unless they arehighly motivated. Then there will be a system supposedly in place that’s really not functioning at all.
4. Recycling. It’s not enough to capture this stuff 

## - it needs to be recycled in order to get it out ofthe loop and keep it out ofthe environment. The handling ofthe recycling is not simple, but it’s not quite as impossible as it was a couple ofyears ago. The dentist needs to know how to prepare, package and send the collected material to a certified recycler and refiner of mercury. Who will take this stuff! How can it be shipped? Who is liable for it once it leaves the office? Can liability fall back on the dentist if there’s a problem of improper handling somewhere down the road? Past case history indicates that’s possible. It’s difficult, but not impossible, for the dentist to find a way to handle this. It’s much easier if the company that sold the unit also handles the recycling end of it. Some of the companies offer this service, and I’d recommend sticking with a company or dealerthat does include doing this for you, with all the proper regulations and paper trail of liability adhered to. If a companyjust wants to sell you a system and leave you on your own to figure out recycling,

### I don’t think that’s a very good service. How often the collecting and recycling is done will depend on the design of the system.
5. Simplicity of design is a plus. The fewer moving parts and bells and whistles, the fewer things that can go wrong. Easy installationand easy maintenance means fewer problems and lower costs.
6. Quiet operation is a nice feature, though these units are usually installed far away from where staff or patients are.

7, There shouldbe a “Fail-safe” mechanism. What would happen if something clogged the line, or the filter got full too soon, or something like that. Are you going to have a toxic spill on’ your hands? Could it end up shutting down your vacuum pump? Some effectivetype of bypass design should be able to automatically handle these eventualities. These units are usually installed in an out ofthe way location, not often checked or seen by the office staff.
8. The unit should install centrally.

### Lookingback at the office diagram,[Figure 

### 1.] if there are filters set at chairside

### in each treatment room, they can capture all the new amalgam sludge. But all these connecting lines, all the way to the vacuum pump, are caked with years of buildup of amalgam sludge, prophy paste, saliva and crud, like arteries clogged with arteriosclerosis. Clean water passing through these lines is going to continue to pick up mercury and pass it along into the waste stream. This has already been demonstrated (Rubin, 1996). Ifyou install a unit centrally, at the site ofthe vacuum pump, it will effectively clean the whole wastestreambefore dumping into the sewer system.

9. Reasonable cost is always important. Realize that you’ll be paying for a system as well as for some means ofperiodic recycling. It’s a good idea to compare companies on the total cost of having a system over a five or ten-year period, in order to really see how much it will cost.

iCynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy ofOral Medicine and Toxicology Seattle, Washington

We have prepared handouts that outline these features (appendix l), as well as a list of some known manufacturerswho have demonstrated a passable level of effectivenesswith testing protocols through King County IndustrialWaste Division (appendix 5). Summary Acknowledgingthat mercury discharge from dental offices is significantis an important first step to properly managing dental waste. Technological, logistical, financial and emotional concerns have been, and continueto be addressed by both the county and dentists. We have developed some solutions and BMP's cooperatively,and continueto get information to those who need it. The governmentmay be able to provide information and education,possibly incentives and recognition. But it is you, the dentist, who can make the real difference.We.encouragedentists, and any dental societies or organizations, to take the opportunity to act proactively on this matter, helping to protect the environment and gaining some good community relations at the same time. One professional organization,the InternationalAcademy 

### of Oral Medicine and Toxicology (also called IAOMT) has taken as stand. Through its Standardsof Care committee, it has recommended that all its members who are practicing dentists install proper mercury recapturing systems now. This is an excellent opportunity for individual dentists, and for dental organizations to lead the way to a cleaner, healthier environment.Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington

References and Bibliography: Berglund, P. “Quantificationof Mercury Discharges to the Wastewater Treatment Plant”. WEF MonoIogue: ControllingDental Facility Discharges in Wastewater. In pre-publication, 1998. Dickey, 

### P. 1) Database of safer substitutes for household hazardous products :phase one report / by Philip Dickey. Seattle, WA. :Municipality of Metropolitan Seattle, 1990. 2) Database of safer substitutes for household hazardous products :phase two report / by Philip Dickey. Seattle,WA. :Municipalityof Metropolitan Seattle, 1991 Galvin, D.V. Why Household Hazardous Waste Management

### Is Needed. p. 5 1-58 from the Proceedings of the Sixth National 

### US EPA conference on household hazardouswaste management (December3-7, 1991). Publisher info: Andover, MA. :Dana Duxbury & Assoc. Gurbam, F.C. et a1 1979. Control Of Heavy Metal Content Of Municipal Wastewater Sludges. Washington, DC :National ScienceFoundation. Jenkins, D. “The Contribution 

### OfHeavy Metals 

### To Wastewaters From Household Cleaning Products“Report by Reed Corporation for the Soap and Detergents Association, July 1990.
Local Hazardous Waste Management Program (1993) Waste Management Guidelines for King County Dental Offices. Municipality ofMetropolitan Seattle, Seattle, WA.
Daniel P. Rourke. CityAnd County OfSan Francisco Consumer Products Heavy Metals Inventory. p. 301-305 from the Proceedings of the SixthNational US EPA conferenceon household hazardouswaste management (December3-7, 1991). Publisher info: Andover, MA. : Dana Duxbury & Associates. Rubin, P. and Ming-Ho, 

### Y. “Mercu y Vapor 

### inAmalgam WasteDischargedfromDental OfJice Vacuum Units ”Archives of Environmental Health, vol. 5 1No. 

### 4, July/August 1996. I

Savina, G. (1995) Dental Waste Education and Outreach, Project Work Plan. Hazardous Waste ManagementProgram, Municipality of Metropolitan Seattle, Seattle, WA.
The Merck Index. (1989). 11 th Ed., Merck & Co., Inc., Rahway, NJ. Tomchick, 

### L., C. Balogh and G. Savina. “Planningand Implementing a Source Control Program. ” WEF Monologue: ControllingDental Facility Discharges in Wastewater. In prepublication, 1998.Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington
Water Pollution Control Department (1995) Demonstration Testing of Amalgam Wastewater Treatment Units. Municipality

### of Metropolitan Seattle, Seattle, WA. Water Pollution Control Department 

### (1994), Dental Office Project: Testing Treatment Technologies for Amalgam Rinsewaters. Metro HazardousWaste Management Section, Municipality of Metropolitan Seattle, Seattle, WA. Welland, C. (1991). Dental Office Waste Stream Characterization Study. Municipality of Metropolitan Seattle, Seattle, WA.Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington 

### Appendices: Appendix 1. Elements OfAn Ideal Mercury Recovery System


### I

~ Effective 

## - 90-99%
2. No compromisein suction power 3

~ “Hands-Off” operation
4. Recycling provided by vendor aspart of service
5. Simplicity of design - easy installation and maintenance
6. Quiet operation
7. “Fail-safe” mechanism to prevent blockage, leakage, etc.
8. Central installationrather than at chairside
9. Reasonable cost 

## - look at total cost, includingperiodic recycling cost

We recommend thatyou ask questions ofprospective vendors untilyou are satisjed. qpossible, tv to talk with some existingcustomers as references.Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G.Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington
Appendix 2. Mercury Vapor in Amalgam Waste Discharged from Dental Office Vacuum Units Reprinted from Archives of EnvironmentalHealth, Publishedby HELDREF PUBLICATIONS, 1319 Eighteenth Street,NW, Washington,DC 20036-1802. (202) 296-6267 

## * Fax (202) 296-5 149 Reprinted with Permission
Abstract. Clinicalprocedures in dental offices generate quantities ofwaste 

### slurry or fine particulate matter, much of which is derived from dental amalgam filling material. This mercury-containing material is discharged into waste streams via the dental office vacuum pump system. This system also discharges large quantities of air, either into the atmosphere exterior to the office building or into the sewer system, depending on the type of equipment used. The purpose of this study was to investigate whether the dischargedair contained mercury vapor. Paul G. Rubin Ming-Ho 

### YU Broadway Dental Center Seattle, Washington Center for Environmental Sciences Huxley College of Environmental Studies Western Washington University Bellingham, Washington
DENTAL AMALGAM RESTORATIONS ("silver fillings") have been the most widely used fillings for more than 160y. These fillings contain approximately50% mercury (Hg). Elemental Hg vapor has been shown to escape from these fillingsin the mouth.1-9 Skare and Engqvist 10reported recently that the number of afnalgam surfaces was related to the emission rate of Hg into the oral cavity and to the excretionrate of Hg in urine. Some amalgam "scrap" is generated in dental offices when amalgam fillings are placed or removed. The scrap is typically composed of small chunks of amalgammaterial, a slurry of grindings of extremely small particles, water, and saliva. The scrap is removed from the patient's mouth with a chairside suction or vacuum device that is powered by a vacuum pump located in a more remote part 

### ofthe office or building. A mixture ofthe amalgam waste, containingHg, water, saliva, and other debris, travels through pipes and tubing to the vacuumpump, where it is eventually dischargedinto the waste-water line that leads to the municipal sewage system. In some offices, the air and liquid portions of the evacuant are separated in an aidwater separatortank. The liquid and solid materials are drained into the wastewater while the air is vented elsewhere, usually to the outside of the building. Questions have been raised about the ultimate fate ofthis amalgam slurry and the possible environmental impact of its contents, particularly Hg.Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy ofOral Medicine and Toxicology Seattle, Washington

If Hg vapor can be released fromthe amalgam in the human mouth, it is also possible that the vapor could be released from the amalgam scrap. Little information is available about such a possibility. We, therefore, studied air samples collected 

### fi-om eight sites at which air is discharged externally fi-omthe dental office vacuum systems. Material and Method
A total of eight sites were selected within and around the city of Seattle,Washington, for this study. The sites were numbered randomly from one to eight. 

### A single dentist occupied some of the dental offices, whereas others were located in buildings in which a central vacuumpump served several dentists' offices. Some vents were located on the tops ofbuildings, and others were housed a few feet above ground level. Site five had a vent located approximately 1.5 m fi-omthe ground in an alley, and it was proximal to car and foot traffic.
A one-time "spot" air sample was taken at each of the discharge vents, and the concentrationof Hg was determined three times during a 1

## - to 2-mk period. 

### in addition,Hg release during an entire day was studied at site one; air sampleswere taken periodically at 30-min intervals from 7 

### A..M. to 5 

### P. M.
Concentrations of Hg were determinedwith a Jerome 43 1 

### -X mercury vapor analyzer (Arizona Instrument Company [Phoenix, Arizona]). This instrumentwas designed for the accurate analysis ofHg vapor in the workplace environment, for locating Hg spills, and for studies of intra-oral Hg vapor levels. In the presence of Hg vapor, a thin gold film undergoes an increase in electrical resistanceproportional to the mass of Hg in the sample. Sample air is filtered to remove any acidic gases that might interferewith the sensor's response to Hg. The features ofthe analyzer are the following: range =

### 0-0.999 mg Hg/ml, resolution = 0.001 mg/m3, and accuracy = f5%. Air is drawn into the analyzer for 

### 12 s at a flow rate of 750 cc/min. The manufacturer calibrated the instrument for us, and it was sent directly to us immediately prior to this study.
We did not conduct any direct measurements of air volume discharged at these sample sites, but we obtained the manufacturer's specifications regarding volume flow for the different types of vacuum units. This information was used to estimate the total daily discharge of Hg, based on the determinations of the Hg vapor concentrations.Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G.Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington



### Discussion Spot-sample determinationsand results of the 17 samples collected during an entire day at site one were similar (i.e., 0.103 versus average of 0.094 mg/m3, respectively [Table 1, Fig. 11). The "spot" sample appeared to be a valuable indicatorof an individual office's Hg discharge level.
The levels of 

### Hg vapor were higher in older dental offices, comparedwith newer facilities. Relatively high levels of Hg were detected at older office sites, even when no patient was being treated at the time of measurement. This suggested that 

### Hg vapor was being released from amalgam residues that existed somewherein the office plumbing. In one office, a piece of plumbing no longer in use (i.e., an old separating tank) released 0.332 mg/ml 

### Hg vapor, thus implying that Hg vapor could be released from the static residue of amalgam sludge. A simple turbulence of air and water over existing amalgam slurry also seemed sufficient to cause release of Hg vapor. The environmentalor health risks 

### ofthis level of emission is not 

### known. For purposes 

### of comparison, the Occupational Safety and Health Administration (OSHA) cites an 8-h time-weighted average 

### (TWA) Hg exposure limit for humans in the workplace at 0.050 mg/m3, The OSHA also has an ,acceptable source impact level" of 0.2 pg./ml for nonalkyl Hg vapor. Perhaps the total quantity ofHg released in a given period of time is relevant. We could not measure outflow volume of air directly at the test sites. A rough estimate couldbe made, based on manufacturer's specifications.For the types and brands of vacuum pumps seen in this study, we estimated a flow rate of 0.5 to more than 5.0 ml/min. 

### An attempt was made to correlate this information with the test data, making some assumptions on the running time of the pumps per day (they typically 

### run continuously all day), per year, per dentist, etc. The total quantity of 

### Hg released per day per dentist in these test offices was estimated to be 60 mg. Extrapolation 

### ofthat result to 112 

### 000 U.S.dentists," who work at least 200 d each year, led us to conclude that the total quantity of 

### Hg released nationwide each year may exceed more than a ton. 

### A more widespread study and careful volumetric analysis are needed to obtain a more accurate picture.
Whether Hg vapor levels exist-and to what degree -in sewage systems that receive discharge air directly still remainsuncertain.
We would expect the discharge amounts to be similar to the levels reported in this study, but the significanceof occupational exposure to workers in that environmentis a question for further study. Table 

### 1, Fig 

### 1.
Before this study, no data had been published about escape of Hg from dental waste material, under naturally occurring conditions. Release ofHg in our study occurred, absent any extremes of forces or temperatures; therefore, such a result appearsto be cause for some environmental concern.Cynthia Welland Balogh King County Local Hazardous Waste Management Program Paul G. Rubin, DDS Academy ofOral Medicine and Toxicology Seattle, Washington

Table 1.-Concentration of Mercury (Hg) Vapors in Air Samples Collected at Test Sites

No. dentists Concentration Site no. at office site {mgH@m9

1 2 0.103 f 0.011' 2 1 0.013 f 0.001 3 5 0.237 -f 0.020 4 2 0.010 f 0.001 5 10 0.1 68 rt 0.023 6 2 0.060 -f 0.01 1 7 2 0.023 f 0.003 8 4 0.126 f 0.001

Average concentration 0.092 f 0.008

*Concentrationvalues presented as means tions. standard devia0.3

0.25

0.2 r"

c) E 0.15 

## P

0.1

0.05

D D

8 8

8

I

I I t , I I I I I i I 6 7 8 9 10 11 12 13 14 15 18 17 Tlnw ot dty, Hr Fig. 1. Results of Hg analysis for air samples coflected at site one during a day, from 200 A.M. to 5:OO P.M.Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy of Oral Medicineand Toxicology Seattle, Washington



### Results
All the air samples collected for analysis contained, on average, 0.092 mg Hg/m3. The level of Hg, however, varied markedly with sampling site and ranged fi-om0.0 10 mglml to 0.237 mg/m3 (Table 

### 1). Mercury levels were higher in samples collected at sites of older dental officesthan in samples obtained at newer offices. The two sites at which the lowest concentrations were found (sitestwo and four) were at newer offices that contained newer plumbing systems. No attempt was made to record the type of dental procedures that were performed on patients at the time the samples were taken. Some.sampleswere obtained at times during which there was no active-dental treatment being performed by dentists.
The results of

### Hg analysis for air samples collected from 7:OO A.M. to 5:OO P.m. at site one are shown in Figure 1. During the day, a continuous output of Hg fi-omthis particular site was observed. Mercury levels ranged from 0.048 to 0. 160mg/m3 (average = 0.094 m m3).Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy ofOral Medicine and Toxicology Seattle, Washington

References
I



### .Craig RG (Ed). RestorativeDental Materials. St.Louis, MO: Mosby, 1980;pp 

### 8-1 1, 163. 2. Vimy MJ, Lorscheider

### FL. Intra-oral air mercury released from dental amalgams. I Dent Res
3. Vimy Mj, LorscheiderFL. Serialmeasurements 

### of intra-oral air mercury: estimation of daily dose from dental amalgam. 

### I Dent Res 1985; 64:1072-75. 4. Patterson

### JE, Weissberg BG, Dennison Pj. Mercury in human breath from dental amalgams. Bull Environ ContaminToxicol 1985;34:459-68. 5. Vimy Mj, Lorscheider FL. Dental amalgam mercury daily dose estimated from intra-oral vapor measurements: 

### a predictor ofmercury accumulation

### in human tissues. 

### J Trace Elem Exp Med
6. Berglund A. Estimation by a 24-hour study of the daily dose of intra-oral mercury vapor inhaled afterrelease from dental amalgam. 

### J Dent Res 1990; 69: 1646-5 1. 7. ReinhardtJW. Side effects: mercury contributionto body burden from dental amalgam. Adv Dent Res 1992; 6:llO-13. 8. Engle JH, Ferracane JL, Wichmann J, Okabe 

### T. Quantitationof total mercury vapor released during dental procedures. Dent Mat 1992; 8(3): 176-80. 9. Visser 

### H, Pieper 

### K, Isemann 

### M, Stalder

### K. A prospective study on the incidence of mercury levels 

### in dental students. 11.Correlation analysis. Dutsch Zahnarztl 

### Z 1991; 46(8):555-57. 10. Skare 1

### ,Engqvist A. Human exposure to mercury and silver released from dental amalgam restorations.Arch Environ Health 1994; 49:384-94. 11. Welland C. Dental OfficeWaste Stream Characterization Study. MunicipalityofMetropolitan Seattle (METRO). Seattle,WA: Industrial Waste, MS Lab; 1991. 12. Occupational Safety and Health Administration. Safety factors. Fed Reg 1992;57:26048. 13. American Dental Association. Chicago, IL: Department 

### of Surveys, 199 1. 1985; 64: 1069-71.

1990; 3:lll-23.

The authors thank the Arizona Instrument Company for assistancewith the mercury- vapor analyzerused in this study.
Submitted for publication May 25, 1995; revised; accepted for publication December 7, 1995. Requests for reprints shouldbe sent to Paul G. Rubin, D.D.S., F.I.A.O.M.T., Broadway Dental Center, 310Harvard Avenue East, Seattle,WA 981

### 02.Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G.Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington 

### Appendix 3. 

### Testing Protocol 

### for Amalgam Separation Equipment Demonstration Testing ofAmalgam Wastewater Treatment Units
Goal: To consistently demonstrate a minimum of 

### 90 percent removal of MERCURY from amalgam wastewater under representativeconditions.
Each vendor interested in installing amalgam wastewater treatment units within Metro's service area must demonstrate to Metro that the system will consistently remove at least 90 percent of mercury under typical conditions*. This demonstrationmust include installing the unit in representative dental offices. (For the period July 1, 1994to May 

### 1, 1995 'representative dental offices' must include a minimum of three King County dental offices). Vendors must provide Metro with both a descriptionofthe specific testing conditionsassociated with each demonstration dental office and the Monitoring Plan for the demonstration period. The Monitoring Plan should include: (a) a diagram and photo showing sampling location and treatment unit placement in relation to chairs and vacuum pump; (b) composite sampling procedure; (c) sample splitting procedure; (d) sampling handling procedures; and (e) number of samples.
Based on Metro's experiencein characterizingwastewater from dental offices and the performance ofpretreatment systems in other settings, the following are minimum demonstration requirements:
1.

2. ESTABLISH SAMPLING POINT. In most cases the samplingpoint will remain constant throughout the test period, therefore advance consideration for the location of the sample point in relationto the installed unit must be considered. The point of samplingwill usually be located between the operatory chair and the vacuum pump, but in all cases samplingmust occur before amalgamwastewater mixes with water that will not be treated by the amalgam wastewater treatment unit.
SAMPLE TO ESTABLISHMERCURY CONCENTRATIONIN UNTREATED WASTEWATER. Prior to the actual installationof the amalgam wastewater treatment unit, samplingmust consist of a minimum of five continuous weeks of operation to establish a mean weight of dischargedmercury (in grams) based on weekly mercury concentrationsand wastewatervolumes. For each amalgam removal unit, a minimum of one composite sample per week must be collectedtotaling a minimum of 5 composite samples prior to installation. Each weekly analysis must consist of all the representative composite samples (one or more) taken that week. For each sample, the total volume of wastewater and the volume of the

. samplemust be reported. Total weight 

### ofmercury can then be calculated. Each samplemust be analyzed by an EPA or WDOE certifiedlaboratory for total mercury using EPA Method 7470 (or equivalent, e.g. Method 245. 1). Please refer to "Recommended Sampling Protocol for Dental Amalgam Wastewater".Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington PauI G. Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington

3.

4.

5.

6. INSTALL THE TREATMENT UNIT. The treatment system must be installed in a minimum of three dental officesfor each type ofvacuum system (wet vs. 

### dry) for which certificationis sought. The offices shouldbe those which routinely work on several amalgam placements or removals per day.
SAMPLE TO ESTABLISH MERCURY CONCENTRATION IN COLLECTED 

### SLUDGE AND TREATEDWASTEWATER. Following installationofthe treatment unit, the total grams of mercury collected over the five week post-installation test period must be reported based on the total weight of the collected solids and its mercury concentration. In addition, for those treatment units installedupstream of the vacuum pump, treated wastewater must be collected. Sampling shall consist of a &mum of five continuous weeks following installation totaling a minimum of 5 weekly composite samples. Each weekly analysis must consist of the entire representativecomposite samples (one or more) taken that week. SampIes should be taken downstream ofthe installed unit and should not be taken until the unit has reached a “steadystate”. As in #2 above, these samples will establish a mean weight of discharged mercury (in grams) based on weekly mercury concentrationsand discharged water volumes.
REPORT TO METRO. Along with the samplingresults obtained for each installation, the vacuum drop associated with the amalgam wastewater treatmentunit 

## - both objectively (inches of Hg via gauge) and subjectively

## - must be reported. Further, the transferabilityof collected sludge and the method of infection control must be explained. Finally, a description ofthe attentionrequired by the vendor or dentist forproper operatiodmaintenancemust be provided. Questions regarding these requirements should be directedto Rick Renaud, King County IndustrialWaste Investigator, at (206) 689-3007. 

## * ‘Typicalconditions” include, but are not limitedto, the standard practiceuse ofin-line amalgam screens and traps.Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G.Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington
Appendix 4. Recommended Sampling Protocol for Dental Amalgam Wastewater (10/24/94)*
These recommendations are to be used in conjunction with King County’s “Demonstration Testing of Amalgam Wastewater Treatment Units”. They apply to the sampling of treated and/or untreated dental amalgam wastewater collected after the operatory and before the vacuum pump. The sampling “collector” accumulates all operatory wastewater produced during the week (sample). The total volume is then measured and a representative portion taken for laboratory analysis (subsample).
1. Sampling set-up

0 Fittings, tubing and sampler should be installed to avoid rough or low spots where particulate may collect and thus not reach the samplingcollector. 2. Sample collection
To obtain representative samples it is importantthat there are no major deviations fi-omthe typical operatory routine. 

### Do not flush the lines with excess water before or during sampling. Most ofthe metals will be in the particulate matter. Care must always be taken in the collection, splitting and subsamplingof samples with particulate to assure that the particulate is evenly distributed so that the sample is truly representativeof the wastestream. 

### Mix sample within the collector well before subsampling. Cap and invert the collector 8 

## - 10 times and then swirl while pouring sampIe(s)

### to keep the particulatewell distributed. Pour at least one duplicate sample (for analysis) ofuntreated wastewater during the first 5- week test period and one duplicate of treated wastewater during the second five-week test period to demonstrate representative splittingtechnique. Measure subsample volume and total samplevolume such that sample integrity is maintained.

0 Pour all samples, including duplicate(s) into measured sample bottles (approx. 500 rnL,). Pour remaining collected samplein a graduated cylinder (approx. 1 - 5 

### L). Some residue may remain, especially in untreated samples. Rinse particulate residue from the sample collector 2-3 times with a little of the supernatant from the top of the graduated cylinder. Assure that whatever residue film remains is insignificantfor volume measurements. Total the volumes: sum the volumes of those samples poured into the sample bottles and the remaining volume poured from the collector into the graduated cylinder. Record total volume. 0

0Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington

0 Preserve sample(s)with nitric acid to pH<2. Your laboratory may be able to provide this service if samplefs)can be deliveredto them immediately. Follow the analyticallaboratory sample handling procedure. Record type and volume of disinfectant used in the dental office. 0 

## * This protocol was developed to assure sample integrity and interpretabledata and is based upon the I992/93 Dental Amalgam Separation Study conducted by the Local Hazardous Waste ManagementProgram in King County


## a.

e

0

4.

0

0

6

8 Analysis Notify the laboratoryofthe type of sample and the anticipated high levels ofmetals in the untreated wastewater samples (e.g. up to 2000 ppm mercury). High concentrationofmetals can cause instrumentationcontamination and carryover. The laboratoryinstrument used for mercury analysis has a narrow and very low linear range which likely will require sample dilution at and by the laboratory before analysis.
The lab should use care in subsampling and dilutions. Dilutions of 1/10,000 or more may be necessary for untreated samples. Digesting the entire submitted sample and then making serial dilutions using digestion acids may be the best approach. The lab’s QNQC data should verify this. Quality Assurance/QualityControl Use clean samplebottles of a 

### known volume. Test for contamination. Soak in nitric acid solution, if necessary. Your laboratory may provide appropriatebottles or help in bottle selection. CIean the sample collectorbottle:

0 Rinse and wash a 4 Liter or larger sample collection bottle. Soak sample collection bottle and lid in disinfectant (Collect a sampIer blank to check for possible contamination from the disinfectant; if detectedthe disinfectant shouldbe changedbefore samplingbegins. Wescodyne seems to work well.) Rinse thoroughly (8x) with 

### warm or hot tap water Rinse 

### 3x with deionized water Shake out and cap bottles 0
6
0 

### Use a “new” sample collector after instalhg 

### the amalgam removal unit. The expected high levels of metals in untreated wastewater will likeIy contaminate the sample collector used in the first five-weekphase ofthe testing protocol. The lab should provide QNQC information for blanks, standardization, standard reference materials, dilutionfactors, seriaI dilution analysis, samplereplicatesand spikes for every analytical batch (and every ten samples if a batch exceeds ten samples). 

### 2.4Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G. Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington

5. Safety

0 Untreated dental wastewatermust be handled with caution due to its potentially infectious and hazardous characteristics. It is probably prudent to handle accordingto bloodborne pathogen procedures. Appendix 5. Tested Amalgam Separators
The Industrial Waste section of King County has received data from the following vendors 

### as evidence that their specified unit is at least 90% effectivein removing amalgam from dental wastewater in the Seattle area.


### DRNA (tel. 800-360-1001) Metasys (tel. 905-528-0078) R&D Services (tel. 206-525-4994) Rebec (tel. 800-569-1088) Safety-Kleen (tel. 800-669-5984) approval status unknown at this time.
Note: King County acknowledgesthat there may likelybe several other market-available amalgam separationunits or technologies which can meet the minimum 90% removal criteria,but data for these units have not been submitted for 

### our analysis. For example, there were a number 

### of other vendors who began demonstration testing in Seattlebut withdrew from the process 

### in response to the county's decision to postpone the dental waste rule promulgation. Contact Rick Renaud (206-689-3007) for more information.Cynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G.Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington 

### Appendix 6. 

### Dual Chamber Amalgam Waste Separator

Materials:
4” schedule40 PVC pipe 

## - 2@ 12 inches 4” PVC plug - 2 each 4” PVC coupling - 2 each 4” PVC threaded cap - 2 each 

### 4” PVC male adapter 

## - 2 each clear silicon caulk - 1 each Fig. baffle: plastic panel (cut from waste basket)
PVC glue

# - 1 each Nalgene barbed bulkhead fittings (size to fit vacuum hose) 

## - 2 each vacuum tubing 

## - size to fit operatory, several feet - 2 

### 4+~7 

# x 1277

Cost 

### of Materials: Approximately $60.
Tools: Electric drill drill bits: MY, 518” paddle, 1 118” paddle Screwdriver pliers hand saw Keyhole saw or similar tool Utility knife straight edge bar clamp Assembly (make two): 1.
2.
3. 4.

5.

6. 7. 8. Mo&t barbed fitting in cap according to instructions.Depending on cap thickness,you may need to recess holes.* Make two shallow cuts at opposing angels along inside length ofpipe for baffle. Usejig for straight cut. Cut plastic baffle and pressure fit into slots. Mark location 

### of baffle 

### on outside ofpipe. Assemble and glue togetherPVC parts (exceptthreaded cap.) When assembled, baffle will be several inches abovebottom of chamberto allow for sludge accumulation and several inches ofheadspace at the top ofthe chamber. Push short piece of hose or othertubing over inside ofbarbed fittings. The one on the inlet side is to guide wastewater into one of the chambers. A longer one on the outlet side is to extract treated effluent. Hoses must not extend beyond top ofbaffle.” Screw cap on, noting position of inlet and outlet relative to baffle. Test and seal with silicon caulk as necessary. Insert both units in series in vacuum line bew’eenoperatory and pump using vacuumhose as needed.

## * top ofpipe for outlet. Special gaskets or shims may be required to fit curved surfaces. Alternately,mount one barbed fitting 

### off center

### in cap for inlet and otherbarbed fitting nearCynthia Welland Balogh King County Local Hazardous Waste Management Program Seattle, Washington Paul G.Rubin, DDS Academy of Oral Medicine and Toxicology Seattle, Washington

Cynthia Welland Balogh works 

### for the Technical Assistance and Pollution Prevention Local Hazardous Waste Program for King County in Washington. She has been involved locally and nationally in dental amalgam characterization and treatment since 1990. She can be contacted at the Technical Assistance and Pollution Prevention Local Hazardous Waste Program, King County, 130Nickerson Street, Suite 100, Seattle, Washington98109-1658. Phone: (206) 689- 3075. Fax: (206) 689-3070. Paul Rubin,DDS, FIAOMT is co-chair ofthe Environmental Committee of theInternational Academy of Oral Medicine and Toxicology, where he also serves on the Board ofDirectors. Dr. Rubin is in private practice ofdentistry in Seattle. He graduatedfrom the University of Washington School ofDentistry. He can be contacted at 310Haward Avenue East, Seattle, Washington 98102. Phone: (206) 324-1100.Fax: (206) 324-671 

### I.Patricia White MedSafe, Inc. Waltham, Massachusetts 

### Dental Office Waste Management: Safety and Regulatory ComplianceIssues.

* Regulatory Compliance

Accreditation & CertificationPreparation Corporate Compliance Topics to be covered

* Waste management safety & liability areas of concern in dentistry

Specific OSHA issues related to waste management How to develop your own compliance program



### WHAT HAPPENS TO YOUR 

### WASTE? .by MedSafe's Compliance Department A typical response -"Some guy picks it up, and he takes care of it. What they do with it is their problem!" Unfortunately, it 

### is your problem and the ultimate disposition 

### of waste is your responsibility. The term "Cradleto Grave" is commonly used when discussing regulated waste issues. If you generate regulated waste (sharps, fixer solution, others) you are responsible for it ..forever. It is very important that you check with your waste hauIer for appropriate licensing. 

### If your questions are not taken seriously or are responded to in a defensive manner, you might consider Iooking elsewhere



### .. there are many!
The following guidelines should be helpful in locating an acceptable Treatment Storage and Disposal Facility 

### (TSDF): Initial screening During the initial screening 

### of a TSDF, 

### you should ask for a copy ofpermits held by the company. It is important to see that the waste hauler has a current permit and is licensedto accept and treat your particular type of waste. This information should be readily available.
You should also ask specific questionsconcerning qualifications and training oftheir staff members. Their employees must be trained in Occupational Safety and Health Administration (OSHA), Environmental Protection Administration(EPA), and Department ofTransportation (DOT) regulations.Patricia White MedSafe, Inc. Waltham, Massachusetts Your interview should also determine the type oftreatment that will be rendered for your particular types of waste. You need to know ifyour waste will be incinerated or if it will be buried in a landfill--where it can eventually come back to haunt you!
Take the Tour
Consider conducting an on-site tour of the waste facility. While in many cases this may not be practical, you might ask your professional association to go for you. As unexciting as it sounds, it could save you from making a costly mistake. Ifthe waste is not disposed ofproperly, if it's found washed up on a beach somewhere, you, as the generator of that waste, are the one who Pays. If you visit, you should be interested in seeing the storage and treatment areas of the facility. Assess the geographical location ofthe facility and its potential ramifications. For example, if it is located in a neighborhood,next 

### to a playground, or near a stream, it is probably not your best choice. It may still be acceptablebut there should be an in-depth review ofhealth and safety practices, storage containment and transfer stations, security and warning signs, etc. Again, appropriate operatingpermits shouldbe reviewed and copies retained for your files. It is important to know that even though that generator possesses a permit, this does not relieve you ofresponsibility for proper disposal of your waste. Permits may be expired or revoked. 

### A call to the state licensing authorities is probably well advised.
Financial Resources
Examine the financial health of your waste hauling company. Financial resources need to be adequate in case the waste facility is closed. If it lacks adequate financial resources, the generator--that means you, again--can be tapped for the cost of closure. Choosing a TSDFrequires more study than merely analyzingthe cost and frequency of pick-up of your waste. Take a few steps now to minimize your risk. Be wise, be informed, and be responsible. Waste Management in context


### ... j.. how you deal with waste is part ofyour facility's overall compliance program

### ... .Patricia White MedSafe, Inc. Waltham, Massachusetts Safety/RiskManagement Program Components Facility Safety Policy Statement Hazard Communicationand Exposure Control Program Program Overview Program 

### Summary The Hazard CommunicationPlan (HCP) Hazard Communication Standard Hazardous Chemical Inventory Procedure Hazardous Chemical Definition Material Safety Data Sheet (MSDS) Overview Hazardous Chemical Labeling Chemical Labeling Guidelines 

### MEDSAFEB Hazardous Material IdentificationChart Exposure Control Plan (ECP) Occupational Exposure to Bloodbome Pathogens Exposure Determination Epidemiology: Diseases and Symptoms Universal Precautions Clinical Protocols Standard Operating Procedures (SOP'S) Handwashing Glove Protocol Treatment Area Maintenance Protocols Laboratory Procedure Protocols Housekeeping Cleaning & DecontaminationProtocols Protocolsfor Using Chemical 

### Disinfectants/Sterilants
Blood Spill Protocols Laundry Waste Management Communication of HazardsPatricia White MedSafe, Inc. Waltham, Massachusetts Hepatitis B Virus (HBV) Vaccination Program Post-Exposure Evaluationand Follow-Up Training and Communication Recordkeeping Employee Training Acknowledgment Contractor Training Acknowledgment (Optional) Fire Extinguisher Location Chart (Optional) MSDS Request forNew Products MSDS RequestFor In-Stock Products HepatitisB Vaccination StatusForm Hepatitis B Vaccination Declination Form Post-Exposure Evaluation Packet Summary Post-Exposure Evaluation Check-Off List Source IndividualPost-Exposure Notification Accident InvestigatiodIncidentReport Employee Post-Exposure and Follow-Up Examination StatusForm Healthcare ProfessionalOpinion Form (Exposed Individual) Healthcare ProfessionalOpinion Form (Source Individual) Cleaning and Decontamination Schedule S-pore TestingLog (Optional) PPE Monthly Inspection(Optiona1) PPE Monthly Inspection Log (Optional)
TB Section Appendix A: Standards 1.



### .................................... Hazard Communication Standard (29 CFR 1910.1200) 2.



### ............................................ Occupational Exposure to Bloodborne Pathogens 3.

...........Access to Employee Exposureand Medical Records (29 CFR 1910.20) Appendix B: Glossary of Common Terms Appendix C: Sample OSHA Forms Appendix 

### D: References Not Cited MedSafe Order Forms:



### .............................................................. MedSafe Order Forms Appendix E: Resource GuidePatricia White MedSafe, Inc. Waltham, Massachusetts 

### Regulatory andAccreditation Requirements at 

### a glance.



## .. 

# Healthcare Organizations

# REGULATORY COMPLIANCE* D OSHA Compliance On-site Audit ofHazards & Documentation Review ofExposureRisks Written Report ofRecommendations Hazard Communication BloodbomePathogens TB Prevention Ergonomics Lifting Safety Air Quality Violence in the Workplace General Safety Lock Out /Tag Out FireElectrical Safety Ladder SafetyFallProtection MSDS Management Hazardous Product Labeling System On-site Auditwith Recommendations Procedures ManualDevelopment QNQCPrograms Initial Staff Training OngoingProgram Maintenance
Title 111, FacilitiesAudit Written Bamer Removal Plan ComplianceDocumentation ADA SensitivityTraining On-site Audit with Recommendations ComplianceDocumentation OngoingProgram Maintenance Information and Reporting System 

# a Program Maintenance ProgramUpdates New Hire Training Quality

CLIA Compliance

D ADA Compliance



## n Controlled Substance Management

Initial StaffTraining Multi-Site Safety Management



### *All programsmust be site-specific 0 CORPORATE COMPLIANCE Evaluation Documentation Training Fraud & Abuse Stark I/StarkII 

### CI ACCREDITATION PREPARATION* # Managed Care ComplianceROC Survey Preparation (JCAHO,AMA, NCQA, AAAHC) UtilizationManagement Credentialing Preventative Health Rights and Responsibilities Medical Records Quality Improvement Practices & Procedures Development
0 

### LOSS REDUCTIONDUSK MANAGEME 0 Employee Policies Employee Handbook Harassment Training Violence in the Workplace Purchase/Sale Reporting FacilityRisk Management # Due DiligencePatricia White MedSafe, Inc. Waltham, Massachusetts 

### Compliance and Accreditation requirements

### for Dental and other Healthcare Facilities
General areas to be addressedby a dental organization include the following: 

### A. Safetv and Regulatorv Compliance Requirements Primary Components
1. OSHA Compliance and Hazard Assessment A thoroughreview of your facility’spractices and procedures,work environment exposure risks and existingrisk managementkafetyprograms shouldbe conducted,with formal written recommendations provided to management, to assist in the development and implementation of appropriate corrective actions.
2. Safety Compliance Manuals and Documentation The organization or facility must develop facility specific Compliance Manuals and documentationincluding OSHA’s Hazard Communication,Bloodborne Pathogens and General Safety standards individualizedto each facility plus abstracts and reference materials for relevant regulations. (This could include state mandated X-ray, Chemotherapy, safety committee or other written safety plans as specified.)
3. Material Safety Data Sheet (MSDS) Manuals and Product Labels A time-consuming, yet critical component of a facility safetyprogram is the assembly of required 

### MSDS Directory and Catalog individualizedto your facility, along with labels for all hazardous products transferred to secondary containers. 4, Staff Training Complete Staff Training should be provided through on-sitetrainings at your facility, consisting of approximately3 hours of instructionper session (in satisfactionof 

### OSHA’s29 CFR 1910.1200and 29 CFR 1910.1030).
5. Ongoing Program Maintenance The employermust make an ongoing commitmentto program maintenance, through (a) continuing documentation updates reflectingnew or revised regulations, specific advisories and newsletters, (b) ongoing training availability for new hires, and training for all staff as regulations change, (c) ongoing MSDb acquisitionand documentation update, (d) a program of follow-upinspections and site visit reports to management, as well as required annual training of staff and, (e) automatic on-site training in the case of a change in a facility’s Program Coordinator.Patricia White MedSafe, Inc. Waltham, Massachusetts 

### B. AccreditationPreparation Requirements Primary Requirements 

### 1. On-Site Survey and Report A thorough review of areas important to facility accreditation issues should be conducted, including:
Office environment Practices and procedures Appointments and scheduling Quality Management Medical records Policy documentation

0 Informed consent, follow-up Medication Billing and collections

0 Safety and infection control Contracts Termination of care
0 Other specialty specificprotocol

2. Development of Required Documentation For any deficiencies identified,physician organizationmanagement must then continue with developmentofrequired plans and/orpractices and procedures (including any plans identified under ‘otherregulations’, see section C below, if necessary).
3. Orientation to Accreditation Accreditation preparation involves changes in organizational culture and procedure. Facility Coordinator(s) shouldbe designated. These individualswill take a substantial part of their time training staff, and conducting workshop/conferenceswith management as to performance oriented ongoing responsibilitiesfor accreditation and MCO provider contractmaintenance.
4. Ongoing Services Regulations change, 

### thus the facility Program Coordinator’s job description into the future will include revision ofplans and/orpractices and procedures developed in this MCONCQA compliance program as driven by MCONCQA initiative.Patricia White MedSafe, Inc. Waltham, Massachusetts 

### C. 

### Other Regulatory Requirements/Suggestions
1. Safety Committee If not already in place, a safety/accreditation committee provides an excellent vehicle to support ongoing training and program-related implementation issues. SUGGESTION
2. Americans with Disabilities Act (Title 

### III) Compliance An on-site facility and compliance audit, preparation ofbarrier removal plan and office policy and ADA awarenesstraining for staff is required for all healthcare facilities.
3. Controlled Substance Management Program An on-site audit ofyour facility’s degree of compliance with the Federal Controlled Substances Act, written recommendations for correctivemeasures and a complete training program and manual providingrequired protocols and documentation should be conducted for all applicable facilities.
4. High Risk 

### TB Exposure Control Plan A manual based on current CDC recommendationsthat includes a 

### TB policy, screening and testing procedures? treatment? control measures,recordkeeping forms and the tools for performing a risk assessment should be created, and staff members trained on program components. May be required dependingon facility type.
5. Radiation Safety Plan 

### A plan developed according to specific state laws that describes standard operating procedures, registration requirements, personal protective equipment and barrier requirements, radiation dose limits and monitoring, handling ofregulated waste, and provides recordkeeping forms and required postings. May be required depending on facility type. 6. Employee Policies Program Every facility shoulddevelop an EmployeeHandbook and employeepolicies covering benefits, work hours, vacations and holidays, sexual harassment, snow days, hiring, disciplinary actions and some 40 other employment related issues. Such a program has been demonstratedto deflect lawsuits and liability exposure.Patricia White MedSafe, Inc. Waltham, Massachusetts 

### Regulatory & 

### Accreditation Readiness Quick-test Does the facility have a written protocol for an Informed Consent process between the doctor and patient, clearly defining the criteria for when Informed Consent is warranted? Does the facility have a Chaperone Policy that defines when a chaperone should be offered to a patient? Does the facility have a Confidentiality Policy defining restrictions 

### on utilizing answeringmachines when leaving messages for patients? Does the facility have a Hazard Communication/ Bloodborne Pathogens manual customized with facility-specific information? Does the facility have a written controlled substance (DEA) managementprogram, including accounting controls? Does the facilityhave a written Americans with Disabilities Act Barrier Removal Plan? (requiredby law) 

### Is there an eyewash, and is it properly mounted and accessible? Has industrial hygiene and x-ray monitoring been conducted? Does the facilityhave 

### a written Employee Policies Manual, includingharassment, workplace violence, and hscrimination? Does the facility have a written protocol for surface disinfection? Does the facilityhave a written 

### TB Prevention Program Does the facility make Hepatitis vaccination available to all "at risk" employees, and is this program documented? Does the facility follow 

### a formal, written Post-Exposure Evaluation and Follow-Up protocol for use in the event of an exposure incident? Does the office have MSDSs for every product in use, organized for quick access? (Generic,non specificMSDSs do not count!) Do all secondary containershave appropriatehazard labels, and does labeling system cross-reference with 

### MSDS Book? Are fue and evacuation plans documented? Is on-sitejob-speciJc annual Staff Safety Training provided by a qualified instructor? (required annually by OSHA) 

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### CI No # NoPatricia White MedSafe, Inc. Waltham, Massachusetts ButviciuJ. White is a CertiJiedDental Assistant and President-elect of theAmerican Dental Assistants Association, where has served for severalyears as trustee for the First District of the American Dental Assistants Association. With MedSafe, aprovider ofsafety, risk management and regulatory consultation services, Pat is involved with the implementation of MedSafe ’s Regulatory Compliance Programs for the company’s healthcare organization clients. She can be contacted at MedSufe, Inc., 69 Hickory Drive, Waltham, Massachusetts 02451. Phone: 1-800- 862-6675. Fax (781) 684-0525. E-mail: pwhite@medsafe.com. WebPage www.medsafe.com.

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