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		                            261 The remaining constituents commonly include copper, tin, and silver. ( - "% Through the Great Lakes Binational Toxics Strategy (GLBTS), Canada and the United States have committed to reduce the use and rel ease of mercury. A Mercury Workgroup, led by Environment Canada and the U.S. Environm ental Protection Agency (USEPA), promotes activities that will reduce mercury releases to the Great Lakes Basin, utilizing the GLBTS analytical framework for achieving virtual elimination of mercury from the Great Lakes. This analytical framework involves a f our-step process of 1) information gathering; 2) analysis of current regulations and programs; 3) identification of cost-effec tive options to achieve further reductions; and 4) implementation of actions to work towards the goal of virtual elimination. This report is an effort by the Mercury Workgr oup co-chairs to contribut e towards the process of utilizing this analytical framework, with a focus on steps 2 and 3. This report is meant to facilitate a dialogue about options th at state and local governments have for addressing mercury re leases from dental offices, whic h has become a growing concern in both Canada and the United Stat es as larger sources of merc ury are controlled and efforts to reduce mercury focus on smaller sources. It is based in large part, though not entirely, on a meeting that the Mercury Workgroup hosted on December 2, 2002, in Chicago, to discuss the issue of dental mercury and ways of reducing the environmen tal impact of dental amalgam. Approximately 50 percent of dental amalgam is mercury. 1 Mercury in dental amalgam can enter the environment in a variety of ways. When amalgam restorations are placed in or removed from teeth during dental work, amalgam can enter dental wastewater; when it reaches a wastewater treatment plant, a small percentage of the mercury in the amalgam will be discharged by the plant. A study by the Association of Metropolitan Sewerage Ag encies found that dental offices are the largest source of mercury to publicly owned treatment works (POTWs), contributing more than 35 per cent of mercury influent to the POTWs studied (AMSA, 2002). While amalgam has very low solubility in water, a small percentage can be released in a bioavailable form, and be convert ed to methylmercury, the formthat accumulates in the food chain, presenting potential health risks to human s and wildlife who consume contaminated fish. Most of the mercury that reaches sewage treatment plants (in excess of 90 percent) is likely to be captured by the treatment plant and enter the sewa ge sludge. Once mercury is in sewage sludge, it is likely to be released if the sludge is incine rated. Some of the merc ury can also be released when sludge is land applied or landfilled, though this is an area that has been little studied. In addition, dental amalgam waste that is generate d (for instance, excess am algam that is not placed in a tooth, or amalgam that is captured by traps and filters in the dental office) can release mercury into the environment if it is not managed properly. In the United States, dentists use an estima ted 35 tons of mercury annually (ENVIRON), which may be placed in teeth, recycled, discharged into wastewater, or disposed as waste. In Canada, approximately 0.6 tonnes of mercury in new dental filling material is placed each year2 Biosolids are the nutrient-rich organic product of wa stewater treatment. Biosolids are a valuable resource containing essential plant nutrients and organic matter and can be recycled as a fertilizer and soil amendment.  (CCME). Mercury use by this industry, as the number of amalgam restor ations, has declined (a 29 percent reduction between 1990 and 1999). While the use of dental amalgam has decreased, amalgam is still considered a safe, durable, long-lasting, and cost-eff ective restoration. Due to thes e properties, amalgam continues to be used for dental restorations, notably in public health care (e.g., military, Medicaid patients). While alternatives to amalgam are available and are used increasingly, most dentists wish to have the option of continuing to use amalgam, particular ly for restorations of posterior teeth. Research into viable substitutes continues. However, even as amalgam use declines, old amalgam restorations will be removed for years to come. In some areas, measures have been imple mented to reduce the amount of mercury flowing from dental offices to wastewater tr eatment plants. Both voluntary and regulatory approaches have been undertake n. This report describes the e fforts of four dental mercury reduction programs and co llates the lessons learned from thes e case studies into a discussion of factors that state/provincial or local agencies should consider in implementing their own dental mercury reduction programs.

- " There are many reasons for initiating a mercury reduction program for dental offices. Reducing concentrations of merc ury in dental wastewater canhave the following potential benefits: reduce mercury loadings to POTWs, decrease the environmental impact of dental mercury wastes, help a POTW or municipality comply with local and/or state discharge limits, and improve the quality of POTW biosolids. 2 For instance, in King County, Washington, the wastewater treatment agency cons iders high-quality biosolids a priority because these biosolids are land applied. If these biosolids could no long er be land applied, eith er due to a change in public perception or for a regulatory reason, Ki ng County would be faced with the much more expensive option of sending biosolids out of state to be landfilled. Recycling the amalgam waste collected through a reduction program (for metal constituents, including silver) provides an added benefit of reduced merc ury releases from improper wast e handling. Also, for dental offices, installation of state-of-the-art amalgam separator equipment can offer a marketing edge for environmentally aware patients.
POTWs in the Great Lakes states are comin g under pressure to meet the water quality standards developed under the 1995 Great Lakes Water Quality In itiative. Mercury is one of 22 “Bioaccumulative Chemicals of Concern” id entified in the Great Lakes Water Quality3 The water quality criterion for protection of human health initially set by the Great Lakes Water Quality Guidance was 1.8 ng/L. However, subsequent to publication of the Guidance, USEPA published a reference dose for methylmercury which, if used, would result in a criterion for mercury of 3.1 ng/L. Great Lakes States’ adoption of 3.1 ng/L as the water quality criterion for protection of human health for mercury was therefore considered consistent with the Guidance and was approved by USEPA. 2 Guidance with water quality criteria of 3.1 ng/L for protection of human health 3 and 1.3 ng/L for protection of fish-eating wildlife. While merc ury at these levels was previously difficult to detect, or was undetectable for some analytical methods, in 1999 USEPA adopted Method 1631, which uses oxidation, purge and trap, and cold vapor atomic fluorescence to detect mercury levels in water as low as 0.2 ng/L. Method 1631 has demonstrated that POTW effluent mercury levels are exceeding the stringent effluent limitations set by the Gr eat Lakes Water Quality Initiative. This has caused an increased focus on the dental sector as a source of mercury contributing to levels in POTW effluent. Wastewater treatment plants are a source of mercury to water bodies , fish, crops, and the atmosphere. A dental mercury reduction program captures am algam waste and reduces the amount of mercury moving into municipal sewers and being dis posed of improperly. Lower levels of mercury at the POTW decrease the amount of mercury entering the environment through POTW effluent discharg ed to water bodies, through wast e incineration, and in sludge use or disposal. Dental mercury reduction programs have been cl early shown to reduce mercury in POTW influent and sludge. The results of a Community-Wide Dental Mercury Study, undertaken by the Metropolitan C ouncil of Environmental Services , in partnership with the Minnesota Dental Association, showed that the us e of amalgam separators at dental clinics in two Minnesota cities achieved reductions in mercury levels of 29 percent to 44 percent in just three months, as monitored by mercury loadings in POTW sludge at two wastewater treatment plants (Berglund, 2002 – Study coordinated by Cl aude Anderson, MCES). Preliminary data have shown reductions in merc ury levels in sludge at Toronto’s wastewater treatment plants of 40 percent to 70 percent as a result of a “Sewer Use By-law” requiring the installation of an amalgam separator and imposing a discharge limit on dental offices in Toronto. Reductions of 80 to 90 percent in mercury levels in the infl uent, effluent, and sludge at the Western Lake Superior Sanitary District (WLSSD) in Duluth, Minnesota, have been achieved as a result of WLSSD’s many pollution prevention efforts, which include a dent al waste management program. The impact of dental amalgam discharge on the environment is a subject of debate. The mercury contained in amalgam is elemental merc ury, not methylmercury, the organic form that can bioaccumulate in fish and animal tissue and that is therefore considered “bioavailable.” Amalgam can break down, however, and release mercury into the environment, where it can be transformed into methylmercury. Nonetheless, si nce some percentage of amalgam discharges are likely to be buried in sediment s before methylation can occu r, environmental releases of amalgam probably are less environm entally damaging than releases of other forms of mercury.9 In addition to amalgam releases, dental o ffices release some dissolved mercury and methylmercury. A recent study has shown that methylmercury is actually formed within dental effluent at large clinics. Methylmercury levels can be higher in the holding tanks of large dental clinics by an order of magnitude in comparison with levels seen in the natural environment (though still a small fraction of the total mercury). The high levels in holding tanks are likely the result of methylation by bacteria and fungi ( Stone, et al., in press). Effluent from smaller dental clinics, without effluent hol ding tanks, have not been studied, and may contain lower concentrations of methylmercury. Assessments of the potential benefits of reducing the di scharge of amalgam can be difficult, given the uncertainties surrounding:



###  the typical dental office wastewater discharge stream (due to the daily variation in the amount of dental amalgam discharged and the differences between dental practices); 

###  the fate of mercury in amalgam (whether it is captured in traps or filters, dissolves, settles in lines, reaches the treatment plant, etc.); and 

###  the percentage of bioavaila ble methylmercury that is released from amalgam under different circumstances. Dr. Phillip Watson, of the University of Tor onto College of Dentis try, conducted a study to measure the percentage of amalgam waste entering dental office wastewater from the removal of dental amalgam restorations. A typical office system was replicated in a laboratory setting, and 160 amalgam restorations were removed in four test runs. The study found that approximately 40 percent of the amalgam removed was captured by a chair-side trap and a filter screen placed just upstream from the vacuum pump; the remaining amalgam, approximately 60 percent, was released to wastew ater. The study also showed that, for the study’s set-up, the average concentration of mercury in wastewat er was 31.15 mg/L without an amalgam particle separator and 0.18 mg/L with anamalgam separator, a differe nce of 99.4 percent (Watson, 2002).
ENVIRON International has developed an “Assessment of Mercury in the Form of Amalgam in Dental Wastewater in the United States” for the American Dental Association (ADA). ENVIRON estimates that de ntal offices release approximately 29.7 tons of mercury into their internal wastewater annually, and that captu re by existing equipment in the dental office (chair-side traps and vacuum f ilters) reduces the amount discharg ed annually to sewage treatment plants to 6.5 tons. This assessment utilizes es timates that chair-side traps capture 68 percent of amalgam, and that 80 percent of U.S. dental facilities are equipped with vacuum filters that capture 40 percent of the remaining mercury. Based on studies showing an average of greater than 95 percent capture efficiency for mercury at sewage treatment plants, the ENVIRON study estimates that POTWs discharge to the water 0.3 tons of the dent al mercury that they receive from dental offices, with the remaining 6.2 tons ending up in sludge. These estimates effectively demonstrate that a significant portion of dental mercury ends up either in waste that must be managed by the dental office or in sewage sludge that must be managed by sewage treatment plants. While mercury discharges to surface waters may also be5 significant in many local circumstances, dent al mercury reduction efforts should not focus exclusively on that fraction (Drummond, 2002). The ENVIRON study also makes estimates of the fate of some of the estimated 6.2 tons of mercury in sludge. It estimates that approximately 1 ton of dental mercury in sludge is managed via incineration, resultin g in air emissions of 0.2 tons of mercury, based on USEPA estimates that emissions controls at sewage sludge incinerators reduce mercury releases by 79 percent. It was further estimated that approximately half of these emissions would deposit in the United States. ENVIRON made no estimate of re leases from the remaining 5.2 tons of mercury in sludge, which are either landfilled, or applied to land as a soil amendment. Dental offices are thought to release less mercury to the environment than many other industries (electric utilities are thought to release 48 tons of me rcury to the air annually, for instance). These releases may still be environmentally important for the following reasons:



###  Dental offices releas e significant amounts of mercury to sanitary sewers, whereas most industries have primarily air emissions of merc ury, which can be dispersed broadly. Releases to sanitary sewers thatdischarge to water bodi es that have mercury impairments are particularly important. To control mercury di scharges, POTWs have strict discharge limits in many parts of the country (including the Great Lakes region). 

###  In addition to mercury discharges to POTWs, dental o ffices generate substantial amounts of mercury-containing solid waste, which may potentially be discharged to the environment if improperly managed. 

###  Dental office discharges contribute mercury to sewage treatment plant sludge, and the fate of mercury in landfilled and land-applied sludge is poorly understood. To address these releases, municipalities and POTWs have initiated programs to reduce mercury releases from dental o ffices, and have achieved reductions of mercury at the wastewater treatment plant. The U.S. Navy is in the process of installing advanced mercury removal equipment in all dental facilities, including clinics, ships, and field units in the U.S. and abroad.

- ! The removal of mercury from dental offi ce wastewater involves several issues of technology and infrastructure. This section discusses best manageme nt practices, amalgam removal systems, residual mercury in lines, the action of line cleaners, and disposal of dental mercury waste.6 - " Best management practices (BMPs) for dent al amalgam waste are procedures that have been found by experience to effectively reduce th e release of mercury into the environment. BMPs can prevent the release into the environment of excess amalgam that is never placed into a patient’s teeth, as well as amalgam that is discharged to the internal dental wastewater system, through the proper use of chair-side traps and vacuum filters and by recycling excess amalgam. Dental BMPs include procedures for trai ning of staff, good housekeeping, proper disposal, and recycling of mercury-containing material. In some places, use of amalgam separators is now considered a BMP. A few su ggested practices for BMPs are described below. Section 3.2 will describe amalgam separator technologies. Th e following practices are a combination of BMPs from various sources (e.g ., the ADA, the Northeast Ohio Regional Sewer District, and the Sustai nable Hospitals Project). Training of Staff
Dental office staff should be in structed in proper techniques fo r the storage, handling, and disposal of amalgam and amalgam wastes. Employees should also be made aware of relevant environmental and wast e management regulations and hum an safety concerns related to mercury-containing materials. Mercury spill kits, or materials to clean up a mercury spill, should be kept on hand and staff memb ers should be trained in how to properly clean up a spill of mercury-containing material. Th e development of training progra ms or educational curricula can help to keep dental office staff trained. S ection 5.2 discusses a program at Kansas State University to develop and present a dental BMP curriculum to dentists and dental assistants. Good Housekeeping Proper housekeeping can reduce spills and c ontamination of add itional materials. Suggested BMPs for housekeeping include:



###  Keep amalgam and mercury-bearing wa stes out of solid waste (“regular trash”) and out of infectious waste. (Solid wastes ma y be incinerated in some areas, and infectious wastes may be incinerated or autoclaved, thus possibly releasing mercury.) 

###  Clean or replace under-sink traps and su mps, taking care to avoid spillage of the contents from plumbing parts. Remove sludge that may contain mercury, and have it recycled or hauled away as hazardous waste. 

###  Install clear plastic, easily removabl e under-sink P-traps, and have the contents recycled or hauled away as hazardous waste if they may contain inadvertently spilled mercury-containing material. 

###  Avoid using sodium hypochlorite (bleach) to disinfect vacuum lines or other line cleaners that could di ssolve mercury out of amalgam.= 

###  Acids that are used to clean equipment, such as x-ray processors, have the potential to release mercury from old amalgam in clinic sewer lines. Acids should be neutralized before going dow n the drain or be disposed in an alternate manner, such as sh ipping to a waste handler. 

###  Inspect containers of mercury- containing materials regularly. 

###  Store amalgam waste in covered, segregated, and clearly labeled airtight plastic containers. Product Substitution and Use Dental offices should consider using merc ury-free alternatives over amalgam, when possible (e.g., gold, ceramic, porcelain, composite s, polymers, glass ionomers, cold silver, gallium), and follow BMPs for product use to reduce amalgam wast e. For example:



###  Eliminate the use of bulk elemental mercury (also referred to as liquid or raw mercury); 

###  Use pre-encapsulated dental amalgam; 

###  Limit the amount of amalgam generated to what is needed for each restoration; 

###  Salvage and store all scrap amal gam in appropriate containers. Disposal and Recycling Studies have shown that following BMPs for disposal and recyclin g of dental mercury and waste amalgam can significantly reduce the amount of mercury released into the waste stream. BMPs for disposal and r ecycling of dental mercury include:



###  Use disposable chair-side traps; 

###  Use vacuum pump filters and change regularly; 

###  Inspect chair-side amalgam traps frequently and remove or clean as necessary; 

###  Collect used amalgam for recycling regularly; 

###  Use a professional amalgam recycler or certified hazardous wa ste transporter to dispose or recycle scrap amalgam; do not rinse it down the drain or dispose of in biohazard bags. 

###  Participate in bulk mercury co llection programs and events. A checklist of dental BMPs can help dental offices identify areas where they could change procedures and reduce amalgam waste. The ADA has recently published a set of BMPs that it encourages all of its members to use (see Appendix A). The Northeast Ohio Regional Sewer District (NEORSD) pr ovides a checklist of mandatory and recommended BMPs that, when completed, signed and retu rned, may serve as the required BMP plan for a dental office (see Appendix B.)4 The copyrighted ISO 1143 test procedure may be obtained thro ugh the American National Standards Institute, at www.ansi.org. Corrections to the test method may be downloaded for free. Go to http://webstore.ansi.org/ansidocstore/find.asp? and look up “amalgam separator”. 8 -   Separator technologies that rem ove amalgam may be used in addition to filters and traps in chair-side dental units and vacuum lines (WEF, 1999). According to MCES, approximately three-fourths of the amalgam gene rated in a dental office can be removed by chair-side traps and a vacuum filter ( MDA and Metropolitan Council, 2003). With the installation of an amalgam separator, greater than 99 percent of amalgam waste can be captured. An International Organization for Standardization (ISO) standard has been developed for amalgam separators, ISO-11143. Published in 1999, theInternational Standard ISO-11143 Dental Equipment - Amalgam Separators document defines amalgam separators as “an item of dental equipment designed to remove amalgam particles from the waste water from the dental treatment centre, so as to reduce the number of amalgam particles and therefore the mass (amount) of amalgam entering the sewage system ” (ISO, 1999). At the time of this writing, a correction to the ISO standard has been issued, Technical Corrigendum for ISO 11143

. 4

ISO-11143 certification is based on 95 percent or greater effi ciency, when tested using the ISO protocol established in the above document. Some U. S. programs may call for higher removals, up to 99 percent, such as in the Minneapolis/St. Paul, Minnesota, metropolitan area. Laboratories testing amalgam se parators using the ISO-11143 pr otocol should be accredited to conduct the test. (Note that this accreditation may be general, and not always specific to the ISO11143 method.) Not all comme rcially available amalga m separators have been verified to meet the ISO standard. Mercury removal equipment for de ntal offices is widely available on the market. Systems range from particulate removal to systems with oxidation and affinity resins (sorbents) that remove ionic mercury. Remova l of mercury from dental-unit wa stewater to below parts-perbillion levels is possible with commercial systems. Howeve r, current technology will not eliminate all mercury. The ADA has evaluated the efficiency of commercially availabl e amalgam separators (Fan et al., 2002). The ADA evaluated the am algam removal efficiency of 12 amalgam separators according to ISO-11143. The removal technologies evaluated include sedimentation, filtration, chemical removal, cen trifugation, and combinations of removal technologies. The results showed that all 12 amalgam separators evaluated exceeded the ISO 11143 requirement of 95 percent amalgam removal efficiency. In accordance with the ISO standard, the maximum flow rates used by the ADA were those provided by the manufacturers. Table 1 presents the efficiencies of the am algam separators evaluated by the ADA (Fan, 2002).<+'- +'1+5++0/*.+'3+04207

**Amalgam Separator Removal Efficiency Maximum Flow**  **Rate (L/min) Removal**  **Technology** Hg 10 99.99% 0.95 Sedimentation/filtration/ ion exchange MRU (Mercury Recovery Unit) 99.95% 0.75 Sedimentation/filtration/ ion exchange Rasch 890-4000 99.90% 4 Sedimentation/filtration/ ion exchange Amalgam Collector 99.89% 0.5 Sedimentation RME 2000 99.66% 1 Sedimentation Hg 5 99.28% 0.05 Sedimentation/filtration/ ion exchange Asdex 99.10% 0.5 Filtration MSS 2000 98.94% 2.5 Sedimentation/filtration BullfroHg 98.88% 0.75 Sedimentation/filtration Durr 7800 97.66% 12 Centrifugation ECO II 97.51% 3 Sedimentation A1000* 96.09% 3 Sedimentation *This separator has been retested by the manufacturer since the time that ADA published its results: Data for the A1000 (now called the Guardian) indicate 99.3% removal at 3 L/minute (testing performed by a contract lab for Air Techniques, Inc.).

The total price of an amalgam separator includes the costs to purchase, install, and maintain the separator and to remove amalgam wa stes. Separators may be purchased or secured through lease agreements. Typical costs are estimated to range from $300 to $2,000 in purchase price or $300 to $1,800 annually for a lease agreem ent, approximately $200 for installation (or included in purchase price), and $75 to $750 in annual maintenance (includi ng waste disposal). Table 2 presents the reported costs and f eatures of selected amalgam separators.(+'- /*0*+,4+03*/6'04+'1+5++0/*

**Product**

**Name Manufacturer/**  **Distributor Costs**  **a Est. Annual**  **Cost Averaged Over 3 Years**  **b Features**  Amalgam Collector R&D Services CH12: $495/unit; $100/installation; $75/year waste collection fees (unit can be emptied and reused) $270 Chair-side unit; One unit serves one chair CE18: $695/unit; $125/installation; $75/year waste collection fees (unit can be emptied and reused) $350 Centrally-located unit; one unit serves up to 6 chairs CE24: $1,250/unit; $250/installation; $75/year waste collection fees (unit can be emptied and reused) $580 Centrally-located unit; one unit serves up to 12 chairs Asdex c Avprox AS-9: $229/unit; $200/installation; $790/year for replacement filters; amalgam disposal not included $930 (plus filter disposal cost) One filter unit per chair BullfroHg DRNA Dental Recycling North America $200/installation; $600/year service plan includes: equipment and amalgam disposal; $100/year cartridge; $200/year cleaner; repairs not included $970 Standard unit serves 1-6 chairs. Uses 120V AC (to pump treated effluent) $200/installation; $1,200/year service plan includes: equipment, amalgam disposal, cartridge replacement, and repairs; $200/year cleaner $1,470

Durr 7800 Air Techniques This product is no longer av ailable in the United States (February, 2003) ECO II Metasys $260/installation; $288/year service plan includes: equipment, amalgam disposal, cartridge replacement, and repairs; $100/year cleaner $470 One unit serves up to 6 chairs

Guardian Amalgam Separator (formerly known as A1000) Air Techniques A1100 or A1200 (for use with a dry vacuum system): $1,500/unit (includes 2 collectors, cleaner, and recycling of first collector); $200/installation; $750/year replacement kit $1,320

Number of chairs serviced depends on type and size of vacuum system A1300 (for use with a single pump liquid ring vacuum system and 4 gallon tank): $2,995/unit (includes 2 collectors, cleaner, and recycling of first collector); $200/installation; $750/year replacement kit $1,820

A1400 (for use with a dual pump liquid ring vacuum system and 8 gallon tank): $3,255/unit (includes 2 collectors, cleaner, and recycling of first collector); $200/installation; $750/year replacement kit $1,900

Hg 10 SolmeteX $7,450/unit; $1,000/installation; $2,100/year filter replacement (2 per year) $4917 One unit serves 10 or more chairs; Used to meet a specific discharge limit+'- /*0*+,4+03*/6'04+'1+5++0/*=/,0),34>

(( Hg 5 SolmeteX $695/unit; $200/installation; $500/year filter replacement (2 per year), includes recycling; $200/year cleaner; repairs not included $965 One unit serves up to 10 chairs $720/year service plan includes: equipment, amalgam disposal, cartridge replacement, and repairs; $200/year cleaner $920

MRU DRNA Dental Recycling North America Inc. $200/installation; $1,800/year service plan includes: equipment, amalgam disposal, cartridge replacement, and repairs; $200/year cleaner $2,070 One unit serves 1-6 chairs

MSS 1000 Maximum Separation Systems $968/unit; $200/installation; $165/year replacement settle tank; $185/year tank waste management fees $740 One unit serves up to 11 chairs

MSS 2000 Maximum Separation Systems $1,395/unit; $200/installation; $165/year replacement settle tank; $185/year tank waste management fees $880 One unit serves up to 20 chairs

Rasch 890- 1000 AB Dental Trends $1,190/unit; $200/installation; $397/year replacement canister (1 every 18 months) $860 One unit serves 12 chairsRasch 890-1000 with Rasch 890-4000 addon unit: costs for Rasch 890-1000 plus $718/add-on unit (15-year life span; no maintenance required for add-on unit) $1,100 Add-on unit used to meet stringent requirements RME 2000 Rebec $1,895/unit and installation; $395/year cartridge replacement includes amalgam disposal and repairs; $200/year cleaner $1,230 One unit serves 8 chairs

a Taxes not included in costs. The cost of a “typical” installation is estimated at $200 unless estimated otherwise by the manufacturer/distributor. Most installations take about an hour ($50-$100), but some have taken several hours. Also, replacement/maintenance costs may vary significantly depending on use. Costs as reported by the Massachusetts Strategic Envirotechnology Partnersh ip (STEP) (Oct. 2002) or by Battelle through personal communication with manufacturers (Feb. 2003). b A typical service plan length is 3 years. c Asdex cost from Minnesota Dental Association, Re vised–Features of Approved Amalgam Separators (October 14, 2003), http://www.m ndental.org/professionals/amalgam_recovery/revised_chart/( -
  Mercury and dental amalgam pa rticles that are trapped in existing plumbing present a potential environmental ha zard. Mercury can build up in lo w-lying plumbing areas (e.g., sink traps and sumps) and can be discharged at any time, releasing a “slug” of mercury to the sewer system. A recent study by the U.S. Naval Dental Re search Institute found considerable amounts of residual mercury in de ntal wastewater lines from large dental clinics. Analysis showed that these wastewater lines were capable of leaching mercury at levels that would make them subject to hazardous waste disposal regulations unde r the Resource Conservation and Recovery Act (Stone et al., 2003). The Sustainable Hospitals Project, sponsored by the Lowell Center for Sustainable Production (at the University of Massachusetts-Lowell), provi des technical support to the healthcare industry for selecting products a nd work practices that eliminate or reduce occupational and environm ental hazards. The project recomme nds that dentists clean or replace mercury-containing pipes and plumbing fixtures, especially when new amalgam management practices are adopted, because trapped particles can con tinue to be a source of dissolved mercury in wastewater for years (S ustainable Hospitals, 1998). While residual mercury that has collected in plumbing or equipment lines may be a concern, experience in Duluth, the Twin Cities, and Toronto seems to indicate that reductions of current releases through the us e of amalgam separators can bring about immediate reductions in the amount of mercury reaching the POTW.

-9  Some oxidizing line cleaners used to clean suction lines can mobilize mercury from amalgam and create a potential environmental hazard. Bleach (sodium hypochlorite) is one of the most notable line cleaners for mobilizing merc ury. Figure 1 illustrates the effect of bleach and other line cleaners on the mobilization of mercury from amalgam (Stone et al., 1999). However, many cleaners on the market do not mobilize mercury. Line cleaners that do not appear to mobilize mercury from amalgam particulate include the following (McManus, 2002):
All-In-One E-Vac Evacuation Cleaner EZ-Zyme Gobble Plus Green and Clean MAXI-EVAC ProE-Vac Purevac Sani-Treet Plus Stay-Clean Super-Dent Turbo Vac Line Flush VacuCleanse VAC-U-EZ(2)13- 660/6/()4)?),1),'+,*/,/)')?),1326/+'1+

-8 $ A plan for the proper disposal of dental mercury waste can minimize the entry of mercury into the sewer system, medical wast e, or ordinary trash. A plan for the proper disposal of dental mercury waste can include using amalgam substitutes, where feasible, to reduce the source of mercury, as well as practices to cont rol a dental office’s mercury wastes. Dental mercury wast e typically includes:



###  Non-contact amalgam (scrap); 

###  Contact amalgam (e.g., extracted teeth containing amalgam); 

###  Amalgam/sludge captured by chair-side traps, vacuum pump filters, screens, and other devices; 

###  Used amalgam capsules that visibly contain mercury; 

###  Leaking or unusable amalgam capsules.
While the ADA has recommended that dental offices eliminate the use of bulk dental amalgam mercury, some dentists may continue to use bulk el emental mercury, also known as liquid or raw mercury, for the preparation of am algam. The Ohio Dental Association, and other state and local agencies, have sponsored bulk mercury collec tion and recycling programs as incentives for dentists to recycle mercury-containing material.(9 Amalgam waste may be recycled or hauled away as hazardous waste. Amalgam waste should not be disposed in the regular trash, with infectious waste (red bag), or down the drain. Amalgam-containing traps, filte rs, or screens should not be rinsed over drains or sinks. Amalgam that is collected in separators, chair-side traps, and vac uum filters should be sent to a licensed treatment, storage, disposal, or recyclin g (TSDR) facility. To facilitate recycling and disposal, POTWs or other local organizations ma y maintain lists of dental amalgam recycling companies. The State of Vermont, for instance, maintains a “Dental Amalgam Recycler/Processor” list that de scribes the costs, services pr ovided, and other information about dental amalgam recyclers. A lack of feasible options may be a barrier to the proper disposal of amalgam waste. For example, regulations requiring that service contractors carry certification to haul mercurycontaining wastes might affect the cost and availability of dental amalgam recycling/disposal services in a locality. It may be costly for la rge waste haulers to pick up small amounts of dental waste from a dental office (Samek, 2002). Improve ments in infrastructure, as well as outreach and education, may be needed to lower barriers and improve the rate of amalgam disposal and recycling. State or local agencies could introduce central collection depots that collect and recycle amalgam waste or, as described above, publish a list of amalgam recycling companies. Dentists may not be aware that amalgam wast e can be shipped through a delivery service (e.g., FedEx or UPS) to recyclin g companies or that disposal of amalgam waste may be included in the price of replacement cartridges or amalgam separator service agreements. Documentation of a dental practice’s amalgam waste recycling and disposal activities may be a requirement of a merc ury reduction program. Document ation may be obtained from the recycler or hazardous waste hauler.

9-  This section presents four case studies of dental mercury reduc tion programs. Each subsection describes the dental community (e.g., number of dentis ts in area), type of approach taken, the partners involved, the vol untary or regulatory nature of the program and related issues, budgetary and staff resources needed for the prog ram, type of outreach conducted, results of the program (e.g., changes in mercury influent, effluent, or sludge leve ls), who installed separators, who collects amalgam waste, type of monitori ng and enforcement required, and “next steps.” Note that there are other programs going on as well. The case studies presented here are just a sample. Descriptions and contact information about other programs are provided in Appendix C.(5 9- %
$! Background The King County wastewater treatment syst em in the State of Washington serves a population of 1.4 million in the urban areas of King and Southern Snohomish Counties. Treatment plant effluent is di scharged into Puget Sound. One hundred percent of King County’s biosolids are recycled through land application to croplands and forests or composting. No biosolids are incinerated or landfilled. There is pressure to maintain high-quality biosolids, because of the cost implications of landfilling lowe r quality biosolids that cannot be used for land application. An estimated 1,500 to 1,800 dentists operatein King County’s service area. Approximately 1,000 to 1,300 dentists handle amalgam fillings, and 85 percent belong to a local dental society. From 1995 to 2000, King Count y engaged in a voluntary program to manage dental waste. In 2001, King County announced a mandate for dentists to meet local sewer discharge limits. Initial Approach In 1991 King County conducted a study which c oncluded that the dental sector was a “significant and identifiable” source of mercury to the wastewater system. During 1991-1994, King County underwent a review process, examinin g available separation un its and developing a set of considerations to eval uate separation units. King C ounty published its findings in a guidebook for dentists. In 1994, King County proposed a rule requiri ng dental offices to install amalgam separation equipment to control discharge of mercury-bearing am algam. This first rule was vigorously resisted by the dental community at the local, state, and national levels. In 1995, King County postponed the rule and agreed to work with the dental community to meet mercury discharge limits voluntarily. The reasons fo r undertaking a voluntary program included:



###  Intense resistance to regulation from organized dentistry; 

###  An offer by organized dentistry to collaborate on the issue; 

###  An immature supply infrastructure of amal gam separators and waste haulers (few choices, high prices); 

###  Ability to allow dentists to comply in a more leisurely fashion, without disrupting operations. Voluntary Program 1995-2000 In 1995, the Seattle-King County Dental So ciety set up a standing committee to work with King County on a voluntary basis. These partners met seve ral times a year and pursued a number of activities, including:(6 

###  developing a poster and a handbook for dentists, 

###  writing articles for a dental journal, 

###  mailing information to all members, 

###  co-sponsoring a free waste pick-up event, 

###  presenting a “Green Dentistry” session at two Pacific Northwest Dental Conferences. The Seattle-King County Dent al Society won a regional environmental achievement award for its efforts to educate member dentists concerning mercury in de ntal wastewater. The participation of the Washington State Dental A ssociation (WSDA) was notably absent from these efforts. Other efforts undertaken independe ntly by King County include:



###  advertisements seeking to educate dentists; 

###  outreach to dental supply houses; 

###  outreach to vocational/technical pr ograms for dental assistants; 

###  cash rebates for purchase of am algam separators (up to $500); 

###  technical assistance visits to dental offices; and 

###  promotion of dentists as “EnviroStars”. Figure 2 presents an example of King County’s efforts to promote dentists as “EnviroStars.”

)13- *+0/6%),1/3,02@* /'3,0+2/1+
,0)*0*$//04* ,.)/0+*5 “Red bag” refers to the container used for infectious waste. This waste is typically incinerated. (= Evaluation of the Voluntary Program During the fall of 1999 and spring of 2000, Ki ng County performed an evaluation of its voluntary dental program. King County staff conducted random vis its to 212 dental offices and collected data on the disposal of amalgam scrap, trap amalgam, pump filter sludge, and fixer. Information was also obtained by 1) cont acting three manufacturers who sold amalgam separators in 1999 and 2000 and obtaini ng lists of dental offices th at had purchased and installed separators; and 2) cont acting waste haulers and mail-away fi rms and obtaining lists of dental offices with waste management contracts. King County’s evaluation showed that th e six-year voluntary program achieved the following results:



###  While the state dental association was not involved, the local dental society cooperated in the program. 

###  Less than half of dentists in the King County service area properly managed scrap amalgam. 

###  Less than 25 percent of dentists properly managed chair-side trap and pump filter waste. 

###  25 dental offices installed am algam separators (2.5 percen t of those estimated to place and/or remove amalgam). 

###  About 10 percent of dental offices contr acted with waste haulers and/or mail-away firms. 

###  Hundreds of pounds of mercury from dental amalgams were still being disposed of annually to garbage, ‘red bag’, 5 sewer, and ‘unknown’ places. The costs for King County’s voluntar y program totaled over $250,000. During 1995-2001, an estimated $4,500 was spent on adve rtisements, $24,000 on the production of a poster and handbook, $65,000 on equi pment rebates, $63,500 on field visits, and $100,000 for staff time. Mandatory Program In July 2001, King County informed dental offi ces within their service area that they must meet the local discharge limit for mercury of 0.2 parts per million (ppm). This limit applies to process water only; it does not include sanitary waste from the facility. The compliance deadline given for this mandate was July 1, 2003. New dental practices wererequired to be in compliance with the local limits when they opened. The en forcement protocol for violation of the 0.2 ppm limit consists of a notice of violation, a comp liance schedule, and es calating penalties for non-compliance. In addition, the names of bus inesses that are fined are published in the Seattle Times

.(8 King County advised dentists that to dem onstrate compliance with the local limits they could:



###  install and maintain a King Count y-approved amalgam separator; or 

###  apply for a wastewater discharge permit and show that they can consistently meet the limit without a separator. Dental offices that place or remove amalgam no more than three days each year or belong to an “exempt” specialty, which includes orthodontics, periodontics, or al and maxillofacial surgery, radiology, oral pathology or oral medicine, and some e ndodontics and prosthodontics, need only comply with established BMPs for amal gam. These offices do not need to install an amalgam separator or apply for a permit. However, they need to be able to demonstrate that they place or remove amalgam three days or less each year. This may include keeping a record, with dates, of each procedure performedthat involves dental amalgam. King County provides a “Dental Wastewater Di scharge Fact Sheet” for dentists and a list of approved amalgam separators . King County’s fact sheet for dentists can be found at http://dnr.metrokc.gov/wlr/indwaste/dentists.htm . This fact sheet describes how to meet the wastewater discharge limit. The list of amal gam separators approve d by King County is presented in Appendix D. All King County approved separators are certified as meeting or exceeding ISO-11143 as verified by an ISO testing laboratory.
Dental offices that have installed an am algam separator that is not on the approved amalgam separator list maintained by King C ounty, or that use a nother method of metals pretreatment, must obtain a permit. The cost of a King County dental wastewater discharge permit ranges from $130 to $1,335, renewable ev ery five years (per 2003 fee schedule). King County identified dental o ffice practices that would resu lt in dental offices meeting King County’s discharge limit for mercury (0.2 ppm ). King County offered to accept adherence to these practices as proof of compliance and not require an office to collect and analyze wastewater samples or to obtain a permit to dispose of wastewater into the sewer system. The dental office practices identified are the following: 1. Follow Best Management Practices for amalgam wastes



###  Keep amalgam out of sinks and neve r rinse amalgam waste down the drain. 

###  Clean or replace chair-side traps on a regular schedule and properly dispose of amalgam waste. 

###  Clean vacuum pump filters regularl y, according to the manufacturer’s recommendations, and properly dispose of amalgam waste. 

###  Send amalgam wastes to a licensed TSDR(treatment, storage, disposal, or recycling facility). (King County provides a list of companies that transport waste to a TSDR.) 

###  Maintain all disposal records on site for 3 years.(< 2. Install amalgam separators at each chair or in a central location where amalgam is removed or placed



###  Separators must be approve d by King County. (King County provides a fact sheet and comparison chart for King C ounty approved amalgam separators.) 

###  Maintain the unit and dispose of wastes according to manufacturer’s recommendations. 

###  Keep installation, maintena nce, and disposal records on site for 3 years. Through its web site, King County provide s information about the regulation, how to comply, and who to contact (see http://dnr.metrokc.gov/wlr/indwaste/dentists.htm ). Beginning in 2001 and continuing through 2003, King County field staff, along with Public Health - Seattle, performedinitial, non-regulatory inspections of dental offices to explain the dental office practices recommended for meeting the mercury discharge limit and to assist with implementation of these pr actices. (Public Health also inspected dental offices for its own program goals, including solid waste and hazardous waste issues.) King County offered the following inform ational workshops periodically through April 2003:



###  The King County Approved Amalgam Separator Workshop 

###  The King County Dental Practice Wast ewater Discharge Permit Orientation 

###  The King County Dental Practice Wa stewater Discharge Permit Workshop The Seattle-King County Dental Association sponsored tec hnology fairs in the fall of 2001 and 2002 to display amalgam separators (over 100 dentists a ttended these fairs). King County continues to sponsor a Vouche r Incentive Program thatreimburses qualified businesses for the cost of purchasing and installing pollution prevention equipment like amalgam separators. The program reimbur ses half of what a business sp ends, up to a total of $500. This program discontinued offeri ng vouchers for required am algam separators in 2003. Next Steps After the July 1, 2003, compliance deadline, King County investigators began inspecting dental offices for compliance with the mercury discharge limit (0.2 ppm) and taking enforcement action with offices that are not in compliance.

Results In response to King County’s mandatory program, the Washington State Dental Association and their attorneys met with Ki ng County. WSDA was concerned with how to exempt those offices that do notneed a separator. King C ounty clarified that there were alternatives for demonstrating compliance (e.g., belonging to an ‘exempt’ specialty or applying for a permit and demonstrating continued compliance). King County reports that dentists are comp lying with the mandate . While 25 dentists installed amalgam separators during the vol untary program (1995-2000) , after the mandate, between July and December 2001, 53 dental offices in King County’s service area installed amalgam separators. Another 131 dental offices installed se parators during the period from January to June 2002. During the period fro m July 1 to December 31, 2002, 286 dental offices installed separators, ba sed on data reported by 7 manufacturers (not all manufacturers report data). As of December 2002, a total of 520 o ffices, out of 1,000 estimated to place or remove amalgam in King County’s service area, had purchased amalgam separators. King County reports that, in general, dentists subject to th e mandatory program are not complaining; they are asking how to buy separators (not why). The mandated program is thought to have created a certainty within the profession about what is required by putting all dental offices on a “level playing field.” The mandated program has also brought wider choices in technology a nd waste hauling options to the area, and prices have stabilized. No current data are available on mercury levels in wastewater influent and effluent. King County does track mercury levels in their biosolid s but has not analyzed data for any trends which may be a result of King County’s mandatory program. Costs The estimated cost for King County’s mandatory program from startup in October 2000 through the end of 2001 was approximately $150,000 . In 2002, approximately $145,000 (including overhead) was spent implementing the program. While initial inspections of dental offices were conducted in partnership with Public Health - Seattle from 2001 through 2003, King County’s estimated share of these visits was about $35,000 to $50,000. In 2003, the cost for inspections and program maintenance was approximately $55,000. Depending on compliance rates, this figure is expected to remain the same for 2004. Ultimately, King County’s goal is to decrease the cost of the program each year as it becomes more established and the time spent per inspection is reduced (Magnuson, 2003). 9- $"&$
 The City of Toronto has an estimated 1,700 dental practices, including general and specialty practices. After examining regulations to prevent dental waste from entering the sewer, City Council decided to employ a discharge standard, rather than an e quipment-based standard, with an information requirement. In July 2000, Toronto enacted a “S ewer Use By-law” that required the city’s dental offices to:



###  submit pollution prevention plans by December 31, 2001; 

###  install and maintain dental waste amal gam separators (type not specified) by January 1, 2002;( 

###  limit mercury discharges to c oncentrations less than 0.01 mg/L (0.01 ppm), effective June 30, 2002 (which was exte nded to November 1, 2002). A standard “pollution prevention plan” formwas developed with requirements for each dental office to specify the type of separato r installed; frequency of servicing; plumbing connections; handling of waste fro m the separator; procedures for amalgam preparation; and methods for storage, handling, and disposal of scrap amalgam. The 0.01 mg/L limit is called a “total facility limit,” which is applied at the property line rather than at the separator. Penalties for non-compliance range from $10,000 to $100,000 a day. Monitoring As a method of monitoring compliance, the by -law requires dentists to submit a four-page information form every two years. Toronto City Council also approved th e hiring of four new enforcement officers to monitor compliance with th e by-law. Inspections at every dental office in Toronto were expected to be completed by November 2003. A sampling protocol has been developed to sample wastew ater after the vacuum pump.

Results Some equipment manufacturers have modified their separators and offered a guarantee to meet the discharge limit or to pay the fine. In some cases the discharge limit may have delayed installation of separator equipment because dentis ts were not certain that the equipment would be able to meet the limit. As of January 2003, approximate ly 1,200 dentists in Toronto had installed separators. Preliminary data collected by the City of Toront o indicated that mercury levels in Toronto’s wastewater treatment plants (biosolids) decreas ed by 40 percent to 70 percent between 2001 and 2002 (Krauel, 2002).

Further Issues Additional issues that the City of Toronto has identified for further potential action include:



###  historic contamination of am algam in plumbing and drai ns, and the effectiveness of remediation strategies; 

###  the ultimate disposal of scrap plumbing from dental offices, which is likely to contain waste amalgam; and 

###  concerns expressed on the partof dentists about their ability to comply with the numerical limit and a possible preference for the clarity of a technology standard. 9-
 $%
!
 Background The Western Lake Superior Sanitary District (WLSSD), located in Duluth, Minnesota, is a regional wastewater treatment plant designed to treat an average daily flow of 43 million gallons of wastewater. WLSSD collects wast ewater from cities and industries covering a 50-mile network of interceptor sewers. WLSSD produces biosolids that are used for land application. Since 1985, WLSSD has worked w ith local businesses to monitor industrial discharges, and major industria l contributors are regulated unde r the Industrial Pretreatment Program through a series of routine monitori ng, self-monitoring a nd reporting, and on-site inspections. WLSSD also ope rates a nationally recognizedpollution prevention program. Western Lake Superior Dental Waste Management Program In 1992, WLSSD, in cooperation the local de ntal society, began the Western Lake Superior Dental Waste Manage ment Program, a voluntary prog ram aimed at reducing the amount of amalgam waste being disposed into the sewe r by approximately 50 de ntal practices in the WLSSD service area. WLSSD conducted a survey of waste management practices among area dentists. A cooperative envir onmental team was formed betw een WLSSD and the Northeast District Dental Society. Aninformational brochur e on managing special wastes from dental practices was developed. Also, a reduction of mercury at a major dental facility was achieved by identifying and abandoning the practice of cl eaning out traps by washing down the drain. In 1995, an audit of 10 dental practices show ed that much amalgam was being disposed in incinerated waste streams (i nfectious waste and solid waste) . WLSSD developed a program to increase the amount of amalgam be ing recycled (going to merc ury recovery f acilities). WLSSD developed an educational program that trained staff on how to recycle amalgam waste. The program included training at all dental offices in WLSSD’s service area, presentations at local dental society meetings, presen tations at dental assistant a nd hygienist schools, continuing education classes for dentists and staff, and written materials. Some presentations were given by dentists and dental assistants (e.g., to de monstrate how to dispos e of amalgam waste). In 1996, WLSSD began testing three differe nt amalgam capture devices. In 2000, WLSSD installed 11 devices in the area’s larges t dental building. In 2001, WLSSD and the local dental society received a local grant to purchase additiona l devices. As a result, another 31 dental practices had devices installed by WLSSD, for a total 45 practices with amalgam capture devices. All devices were ISO-certified. Seven practices in WLSSD’s service area remain without amalgam capture devices. One pr actice refused to install the equipment, three have not been contacted, and three need some re-design of vacuum systems before equipment could be installed. Dental offices may dispose of dental amalgam and othe r mercury-bearing waste at low-cost through WLSSD’s “Clean Shop” Progra m. Clean Shop is designed to help small2 businesses and other organizations find responsible and cost-effec tive ways to dispose of very small quantities of ha zardous waste. Participants can dispose of up to 660 pounds of hazardous waste annually through the program at minimal cost. Program Costs Over the 10 year period 1992- 2002, approximately 10 percent of a full-time staff member was devoted to the dental wast e management project. About $20,000 of grant money was used to purchase equipment at $500/unit (all ISO-certified) . Some equipment was also donated by the equipment manufacturers. About $100,000 of national grants (from USEPA Great Lakes National Program Office and the Great Lakes Protection Fund) wa s used for the development of “Best Management Practices” materials locally and for the Great Lakes states dental associations.

Results The Western Lake Superior Dental Waste Management Pr ogram has been a voluntary, cooperative effort between WLSSD and the local de ntal society. A number of factors appear to have contributed to the success of this program:



###  the leadership of the local dental society; 

###  peer-to-peer interaction with area dentists, including explaining the need to properly manage amalgam waste to prevent mercury from entering the environment and demonstrating the proper methods for doing this; 

###  incentives to install amalgam capture equipment (the devices were purchased through grants, and WLSSD performed the installations); 

###  a discount waste disposal option (throug h WLSSD’s “Clean Shop” Program); and 

###  the smaller community (~50 dental practices) allowed a collaborative relationship to be built. As a result of the Western Lake Superi or Dental Waste Ma nagement Program, approximately 100 pounds of raw mercury (no longer in use) we re collected from dentists in the WLSSD service area. Dentists who collect excess mix, chair-side trap amalgam, vacuum pump trap sludge, and separator sludg e are estimated to recycle 1-2 pounds of mercury per dentist per year. In addition, levels of me rcury reaching WLSSD have declinedsteadily. Figure 3 shows the declining trend in the levels of mercury in WLSSD’s infl uent (pounds per day) from 1993 to 2002. Figure 4 shows the declining trend in the le vels of mercury in WLSSD’s sludge. Table 3 shows the decline in mercury levels in WLSSD effluent as amalgam separators were installed. Next Steps WLSSD would like to involve amalgam ve ndors on a statewide basis in Minnesota. WLSSD has obtained letters from dental offices that describe their experiences in installing amalgam capture equipment. These letters explain that installation of equipment that reduces the amount of mercury released into the sewer does not disrupt a pr actice’s operations and, thus, are intended to help convince other dental offices to install such equipment.9 **WLSSD Influent Hg**

**0 0.02**  **0.04 0.06**  **0.08**

**0.1 0.12**  **0.14 0.16**  **0.18**

**0.2**

**J’93 J’94 J’95 J’96 J’97 J’98 J’99 J’00 J’01 J’02 Pounds per day** 

**MERCURY IN WLSSD SLUDGE**

0 0.5

1 1.5 2 2.5

3Oct-94Feb-95Jun-95Oct-95Feb-96Jun-96Oct-96Feb-97Jun-97Oct-97Feb-98Jun-98Oct-98Feb-99Jun-99Oct-99Feb-00Jun-00Oct-00Feb-01Jun-01Oct-01Feb-02Jun-02Oct-02Feb-03**PPM dry**)13
- 32.'*),$,6'3,0=5/3,4*54+2>6/AA
0/=/33/),,
>

)139- 32.'*),$'341=42>6/AA90/=/33/),,
>6 The National Pollutant Discharge Elimination System (NPDES) permit program was established by USEPA, as directed by the Clean Water Act, to control point source discharges. The NPDES permit program defines the conditions and effluent limitations under which a facility may make a discharge into the waters of the United States. Monitoring requirements may also be specified in an NPDES permit.

5+'
- 32.'*),$66'3,0=,1>6/AA80/=/33/),,
>

**WLSSD Effluent Mercury a**  **Year 1995 1996 1997 1998 2000 2001 2002 Mean (ng/L)**  20.6 15.3 11.2 10.1 1.9 **# of samples** 1 1 27 6 19 **Separators installed**  3 11 11 20

a Analyzed using EPA Method 1631.

9-9 !!$ Background The Northeast Ohio Regional Sewer District (NEORSD) serves most of Greater Cleveland. NEORSD is governed by a board of trustees appointed by c ity, county, and suburban governments. Operation is funded by local se wer use charges. NEORSD owns and operates combined-sewer overflow (CSO) facilities, major intercepting sewers, and three wastewater treatment plants. It is the pretreatment control authority in its service area. In 1997, Ohio EPA revised the Ohio water quality rules to be consis tent with USEPA’s 1995 Great Lakes Water Quality Guidance. The revised rules apply to the entire Lake Erie drainage basin in Ohio. Mercury is one of 22 “Bioaccumulative Chemicals of Concern” identified in the Great Lakes Water Quality Guidance with water quality criteria of 1.8 ng/L for protection of human health and 1.3 ng/L for protection of fish-eating wildlife. Evaluating data obtained using the newe r, sensitive EPA Method 1631, the Ohio EPA found mercury concentrations exceeding 1.3 ng/L (the Great Lakes wate r quality criterion for protection of fish-eating wild life) in 98 percent of treated wastewater samples. An Ohio EPA Economic Impact Assessment reported that end-of-pipe remova l of mercury to less than 12 ng/L would cost “$10 to $100 million per pound of me rcury removed” and “... would result in substantial and widespread soci al and economic impact.” As a result of this assessment, the Ohio EPA adopted into its rules a variance from water quality-based efflue nt limits for mercury. One of the requirements for an NPDES 6 permittee who is granted the variance is implementation of a pollutant minimization program (PMP) for mercury.6 In anticipation of the PMP re quirement, NEORSD assisted in planning an Ohio Dental Association (ODA) statewide bulk mercury coll ection and recycling program in 1997. In 1998, NEORSD served as a drop-off site, collectin g 103 pounds of bulk mercury for the ODA program. In May 1998, NEORSD conducted a mercury regulation/disposal seminar for dentists, with cooperation from ODA and the Greater Cleveland Dental Society. In September 1998, NEORSD conducted a seminar at the ODA Annual Confer ence in Columbus, Ohio, and in Fall 1998, NEORSD authored an article on mercury regulation/disposal, wh ich was published in the Greater Cleveland Dental Society Bulletin. In 2000, NEORSD was issued an NPDES permit that required the establishment of a local pretreatment limit to prevent levels of mercury passing through the NEORSD treatment plant from exceeding 1.3 ng/L. NEORSD estimate d the relative contributions of sources of mercury to its system. Due to mercury c ontributions from domestic/background sources and a safety factor, a numeric local limit for mercury was calculated to be a negative value. Dental offices were estimated to be the largest class of sources of mercury, contributing 41 percent of the total mercury influent to NEORSD wastewater treatment plants. Also in 2000, Ohio EPA issued pretreatment guidance on the use of Best Management Practices (BMPs) as industrial local pretreatment limits. Ohio EPA advised that “... local limits ... may be numeric or narrative ... .” NEORSD chose to a dopt a narrative limit for mercury. Administrative Orders In 2002, NEORSD set the following narrative local limit for mercury: “All industrial [i.e., non-residential] use rs that are sources of mercury shall implement best management practices (BMPs) ... to minimize discharges of mercury to the System. Certain industria l users and/or classes of industrial users identified by the District as significant ... shall comply with District-issued administrative orders requiring submittal and implementation of BMP plans ... .” In cooperation with represen tatives of ODA and the Greater Cleveland Dental Society, NEORSD developed BMP plans for dentists in the NEORSD service area. In February 2002, NEORSD held a meeting with ODA and leaders of the Greater Clevel and Dental Society to inform them of its intent to issue administrative orders to area dentists. A list of area dentists was obtained from the Ohio Dental Board. InMarch 2002, NEORSD began a series of free seminars for dentists, with continuing educa tion credits provided by the Greater Cleveland Dental Society. By April 1, 2002, NEORSD sent administrativ e orders by certifie d mail to 1,100 service area dentists. These orders required submission of a BMP plan and implementation at each office no later than December 31, 2002. The adminis trative orders include d both mandatory and recommended BMPs. Appendix B presents th e administrative order issued to dental practitioners and a document provided to dental offices that, when completed, could serve as the= required BMP plan. The goal of the BMP plan is to maintain wastewater effluent total mercury concentrations below 0.2 nanograms per liter (parts per trillion). Table 4 summarizes the mandatory BMPs de veloped by NEORSD for dental mercury discharge minimization. Table 5 summarize s NEORSD’s recommended BMPs for dental mercury discharge minimization. Installation of amalgam separators is a recommended BMP. In addition to a BMP plan, NEORSD require s each dental office to submit an annual report describing the implementation status of its BMP plan, updates to the plan, an updated inventory of potential sources of mercury; copies of an y correspondence that indicates compliance (e.g., waste hauling documentation), and any availa ble information on wastewater monitoring results or the eff ectiveness of the BMP plan. Th e first annual reports to NEORSD were due by March 1, 2003. Program Costs Through 2002, several NEORSD personnel have been involve d in the dental mercury program to constantly varying de grees as parts of their jobs inthe Water Quality & Industrial Surveillance department. Currently, no staff are fully devoted to mercury issues. NEORSD’s estimate of the total cost of staff salaries and be nefits attributable to the dental mercury program during 2002 is approximately $115,000. Estimates of the percent of time that NEORSD staff have contributed to the program during 2002 are the following: one superintendent (10%), one specialist (50%), two supervisors (10%, 5%), and four investigat ors (85%, 6%, 4%, 2%). Costs for the program to date are expected to chan ge as the program begins to be more fully implemented. NEORSD had planned to hire two full-time staff devoted to mercury issues in 2003 (Linn, 2003). Once the two-person mercury crew is in place, NEORSD estimates that the total cost of salaries and benefits attributable to the dental mercury program will be approximately $125,000 per year. Estimates of th e percent of time NEORSD st aff will contribute to the program are as follows: one manager (5%), one sp ecialist (30%), one supe rvisor (10%), and two investigators (80%, 80%). In 2002, the total co st to NEORSD of sampling and analysis for mercury to comply with NPDE S permit requirements and to support the me rcury program was approximately $65,000. Costs associat ed with sampling and analysis for mercury are expected to increase as the NEORSD mercury program intens ifies its efforts in the future (Linn, 2003). Next Steps NEORSD anticipates that the two-person mercury crew will each devote 80 percent of their time to the dental mercury program. Thes e staff will be responsible for performing field inspections to verify BMP plan implementation atdental offices, hospitals , and other dischargers that, as significant sources of mercury in the sewer system, have been issued administrative8 orders. These staff will also be responsible for identifying additional significant sources of mercury and for other mercury-re lated projects such as sampling to quantify mercury levels and public education on me rcury use reduction. Depending on the results of the program inreducing mercury effl uent levels, NEORSD will evaluate the potential need for additional re ductions. If additional reductions are necessary, NEORSD may consider issuing new administrative orders that make mandatory some of the measures that are currently only recommended.

+'9- +,4+0/2"*0+,+1,0+0)*6/,0+'32)*7+1),))?+0)/, **NEORSD Mandatory BMPs for Dental Mercury Discharge Minimization** 



###  Eliminate all use of bulk elemental mercury. 

###  Use only precapsulated dental amalgam. 

###  Any bulk mercury must be recycled or hauled away as hazardous waste. 

###  Bulk mercury must never be placed into the regular trash, in with infectious waste, or down the drain. 

###  Limit amount of amalgam used to smallest appropriate size for each restoration. 

###  Keep a variety of amalgam capsule sizes on hand. 

###  Change or clean chair-side amalgam traps frequently. 

###  Flush the vacuum system before changing the trap. 

###  Change vacuum pump filters and screens at least once per month or as directed by the manufacturer. 

###  All amalgam waste a must either be recycled (preferable) or hauled away as hazardous waste (acceptable). 

###  Amalgam waste must never be placed in regular trash, placed in infectious waste, or flushed down the drain. 

###  Traps, filters, or screens must never be rinsed over drains or sinks. 

###  Store amalgam waste in covered, segregated, and clearly labeled airtight plastic containers or as directed by the recycler. 

###  Maintain a log of amalgam waste generation and recycling/disposal. 

###  Documentation must be obtained from recycler or waste hauler, kept on file, and made available to NEORSD upon request. 

###  Train all staff that handles or may handle mercury-containing material in its proper use and disposal.

a NEORSD defined amalgam waste as contact amal gam (e.g., extracted t eeth containing amalgam); amalgam/sludge captured by chair-s ide traps, vacuum pump filters, screens, etc.; non-contact amalgam (scrap); used capsules visibly containing me rcury; or leaking or unusable capsules.<+'8- /,44"*0+,+1,0+0)*6/,0+'32)*7+1),))?+0)/,

**NEORSD Recommended BMPs for Dental Mercury Discharge Minimization** 



###  Use, when appropriate, mercury-free alternatives to amalgam: - Gold - Composite resins - Ceramic - Porcelain - Polymers - Glass ionomer, etc. 

###  Clean or replace under-sink traps and sumps. 

###  Take care to avoid spillage of contents from plumbing parts. 

###  Remove sludge that may contain mercury, and have it recycled or hauled away as hazardous waste. 

###  Use disposable chair-side amalgam traps in cuspidor and vacuum system. 

###  Have used disposable traps recycled or hauled away as hazardous waste. 

###  Maximize use of the high-speed suction system. 

###  Remove wet cuspidors from service during amalgam restoration/extraction procedures. 

###  Avoid using sodium hypochlorite (bleach) to disinfect vacuum lines. 

###  Be knowledgeable about amalgam separat ors employing enhanced sedimentation, fine particle filtration, and/or other technologies. 

###  Install and properly maintain such technologies that are determined to be feasible and effective.

8- "!  As illustrated by the case studies presented in the previous chapter, a number of different approaches have been employed in dental me rcury reduction programs. In the United States, there are no national regulations imposing mercury controls on dent al offices, so state and local governments are free to determine the best program for their local circumstances, within the requirements set by discharge permits and pollutant minimization plans, in the case of sewage treatment authorities. In Canada, provinces are committed to the use of best management practices to achieve a 95 percen t national reduction inmercury releases from dental amalgam waste discharges to the environment, by 2005, from a baseline of 2000. Within this framework, provincial and local governments in Canada have cons iderable freedom to choose the approach they will take. This section discusses factors that state/pr ovincial and local gove rnments should consider in establishing a mercury reduction program, whethe r voluntary or regulatory.2 8- ! There are different options for leadership of a mercury reducti on program, including different levels of local govern ment or local POTWs. Case studies have shown that successful mercury reduction programs can be implemented at the local level by involving the dental community, through professional de ntistry organizations or indivi dual dental practices. The local dental society and the local POTW can be powerfu l partners in a collabor ative effort to reduce mercury from dental office wastewater. Incentives may be offered to motivate dentists to participate. Free installation, discount waste collection, technical assi stance, equipment rebates, and free seminars with continuing education credits are some of the incentives that may be used to encourage dentists to participate in a mercury reduction program. Costs of a mercury reduction program can vary. Costs include staff time for operation of a program, including field visits, web site maintenance, educational presentations, compliance and evaluation, as well as costs of outreach materials, incentives (e.g., rebates for equipment installed), and wastewat er sampling. Discounts may be av ailable from equipment manufacturers in lieu of rebates offered by a POTW or municipality. Local or regional grants may offer opportunities to help offset some costs. In Canada, the federal and pr ovincial governments have also provided leadership through the Canada Wide Standards pr ocess. A national standard for dental amalgam has been established requiring that den tists reduce environmental releas es by 95 percent by 2005. This standard is expected to be achieved by the collection of dental amalgam waste through the installation of an advanced amalgam separator and the adop tion of BMPs to ensure the appropriate manageme nt of the collected amalgam waste. In addition, the Professional licensing body in Ontario has established a requirement to install an am algam separator as a regulatory standard in order to be licensed to practice dentistry in the province.

8- ! A successful program will most likely involve some type of outreach to the dental community. The outreach may serve multiple purpos es. Outreach may seek to educate or inform dentists, to request their invol vement, to promote a reduction pr ogram, or to share results. Potential methods of outreach include:



###  advertisements 

###  educational curricula, letters, and handbooks 

###  presentations at dental assistant/hygienist schools or dental society meetings 

###  seminars or workshops 

###  technical assistance 

###  technology fairs 

###  visits to dental offices 

###  web sites2( Outreach to dentists can be f acilitated by the fact that the American Dental Association has taken the position that all dental offices in the United States should voluntarily follow ADA BMPs (see Appendix A). For actions beyond th ese BMPs, ADA favors a graduated approach in which mandatory BMPs and mandatory or voluntary installation of amalgam separators are considered, where voluntary effo rts have failed, and where POTW discharges exceed local limits and dental offices are shown to contribute a significant sh are of the mercury problem. Educational programs for dentists and dental a ssistants can be a useful outreach tool. The Pollution Prevention Institute at Kansas State Un iversity has undertaken a mercury educational effort. Through this effort, an amalgam waste f act sheet has been devel oped and a dental waste education curriculum has been presented to dental schools and dent al assistance programs (Larson, 2002). For more information about KSU’s program, visit www.sbeap.org. Some initial sensitivity and defensiveness from the dental sector can be expected. However, case studies have shown that dentists can be willing partners once they understand the issue. Educational materials may be best accepted by dentists when they include scientific facts to explain the problem with mercury in dental office wastewater. Thus, outreach materials should aim to educate dentists on the wastewater issue, about which they may be unaware, rather than place blame. Outreach materials may also need to recognize that, while it must be properly managed, dental amalgam remains a valuable restorative material to the practicing dentist. Sensitive outreach may also facilitate the c ooperation of the dental community, whether the program is a voluntary or regulatory effo rt. Language should be non-judgmental. For example, materials might use the term “non-comp liant” instead of “illega l” to describe the manner in which dental wastes ar e being disposed. Care should be taken to recognize specialty and other practices (orthodontics, periodontics, oral surgery, maxillo-facial, some endodontics and prosthodontics) whose mercury discharge levels are not ex pected to be significant.

8-
  - ! In some areas, the problem of mercury in dental office wastewater can be addressed through voluntary, collaborative efforts. In othe r areas, particularly where significant reductions in mercury discharges by a se wage treatment plant are required for compliance with permit requirements, a regulatory approach may be needed to ensure compliance by the dental community. In some cases, the potentialfor regulation may be sufficient to induce effective, voluntary action, although a threatening appro ach could engender resistance from dentists. The voluntary approach may be easier to imple ment than regulation. Voluntary efforts tend to sustain an attitude of “we’re in it together” and avoid an “us vs. them” relationship between the dental community and the regulating agency, which could hinder cooperation or cause ill-will in a community. A voluntary appro ach may require dental office visits, outreach materials, and/or technical assistance that incur significant costs. If the goal is to have dentists voluntarily install amalgam separa tion equipment, it may be necessa ry to secure grants or public funds to offset or defray the cost of equipmen t. However, a voluntary approach avoids the2 regulatory process of deciding upon an appropriate st andard, writing the regulation, issuing the mandate, and monitoring and enforcing compliance. Even when the goal is ambiti ous, for instance to encourage de ntists to adopt separators, voluntary programs can work, particularly if there is potential for regulation in the absence of successful voluntary efforts. The Minnesota De ntal Association (MDA) has begun to implement a statewide voluntary mercury re duction program, with assist ance from the Metropolitan Council of Environmental Services (MCES) . While this program is volunt ary, it has regulatory backing, because of the potential that MCES and other sewage treatment authorities in Minnesota might impose regulations in the absence of a successf ul voluntary program. The MDA, through this proactive voluntary program, encour ages dentists to use best ma nagement practices for managing mercury wastes, and to install amalgam separators by Febr uary 2005. To date, two-thirds of Minnesota dentists have committed to participate in the program, and 15 percent have installed separators. For more information about this program, see http://www.mndental.org/profe ssionals/amalgam_recovery/. The regulatory approach often requires numerical data as a basis of support for a statute that imposes a cost upon society. The level of me rcury in dental wastewat er is highly variable, changing daily within each office. As a result, obtaining consistent numerical data can be difficult. The regulatory appro ach also requires terms and proce sses to be defi ned. Regulation can also be expensive for both the regulating agen cy and the regulated audience. On the other hand, the regulatory approach presents a clear requirement for all “aff ected” dental offices, typically with a definite time frame for achieving compliance, and a means for measuring outcomes. In some cases, a mandate may be less costly than a pr otracted period of attempts to obtain cooperation from the dental community. Re gulation may also result in a more competitive market for mercury removal equi pment, bringing better products and services, wider choices, and lower prices. If a regulatory approach is chosen, regulators should be su re to provide exemptions for dental specialties that do not handle amalgam. A regulation may set a narrative standard (e.g ., a requirement that dentists use BMPs, or install control technologies) or a numeric limit (on mercury concentration in wastewater discharges). There are advantages and disadvant ages to each type of requirement. The cost of each approach will vary depending on the require ments that are included. Each approach will likely require outreach to educate dentists and monitoring of compliance with the requirement(s). A narrative standard may require that dentists use BMPs to minimize releases of dental mercury, and the use and mainte nance of amalgam separators c ould be a required BMP. This may be the easiest type of requi rement for a dental office to co mply with, and compliance can be monitored through inspections, reports, or other documentation. One advantage of a narrative standard is th at compliance is straightforward and easy to monitor (a practice must install the technology or document use of the BMPs). While it may be22 uncertain whether the required practices and t echnologies will sufficiently lower mercury levels in the wastewater, if separators are required, this uncertainty can bepartly alleviated by requiring that the separator be of a minimum quality (e.g., ISO certified, and tested at an appropriate flow rate) and that certain maintena nce procedures are performed. A narrative standard does not mean that a particular device will be required, only that a device that has been proven effective will be required. Setting a numerical discharge limit might seem appealing, since it would avoid the need to specify technologies or practices. However, this approach require s determination of an appropriate limit and, once the regulation is in effect, testing to ensure that discharges are below the limit. A numerical limit may incur significant costs for a dental practice to be able to meet the limit and to perform testing. Morever, since dental office wastewater is highly heterogeneous, it is extremely difficult to collect a representative sample using traditional composite sampling methods. For these reasons, de ntists are likely to prefer narrative standards to a numerical discharge limit, and regulatoryauthorities are likely to find a technology or narrative standard easier to implement.

8-9  While monitoring and enforcement are typically associated with a regulatory approach, a voluntary program will probably include some type of follow-up with dental offices as well, for example, to ensure that filters are being cleaned properly and that waste materials are being disposed in an appropriate manner. Participation and results of both vol untary and regulatory programs may be monitored through surveys, vis its to dental offices, purchase information from amalgam separator vendors (information on offices that have installed units), information from waste management firms (information on offices that have amalgam waste hauled away), mandatory reports from dental offices, sludge measurements, and tests of discharge and influent/effluent levels. For regulatory programs, the need for monitoring and enforcement will vary with the type of mandate issued, as discu ssed in the preceding section. Monitoring compliance with a technology standard or narrativ e limit might be accomplished through office visits or reporting requirements. Monitoring compliance with a numerical limit will likely involve testing dental office discharges. Sampling may be difficult if it includes collectin g a sample under vacuum conditions and obtaining a representative sample of a heterogeneous waste. Digestion and analytical methods may be difficu lt when amalgam is part of the waste. In addition, a number of variables are associated with te sting wastewater discharges, su ch as when the test should be performed (e.g., on a typical day or while amalgam is being handled), where the test should be performed (e.g., at the vacuum filter or at th e property line), and how often the test should be performed (e.g., one time or once a month and the results averaged over the year). Regulatory enforcement protocols may in clude a notice of violation, a mandated compliance schedule, and escala ting penalties for continued non-co mpliance. Compliance with a voluntary program might be encouraged through corresponde nce or an office visit to determine29 the reason for non-participation and offer technical assistance to he lp dentists meet the objectives of the program.

8-8  The decision to install amalgam separator e quipment involves many practical issues from a dentist’s point of view. Cons ideration of these factors can affect the success of a mercury reduction program. Seve ral issues are presented below, as factors to consider, but are not described at length. (Much of the information presented in th is section is from McManus, 2002). Selection Factors
There are several factors to consider inselecting amalgam separator equipment, including:



###  Cost, including installation, operation, maintenance, and amalgam waste disposal 

###  Whether to purchase or lease a unit 

###  Installation considerations (e.g., available space) 

###  Discounting of future costs 

###  Ease of installation 

###  Ease of operation 

###  Field performance (beyond ISO 11143) 

###  Recycling options 

###  Frequency/ease of maintenance 

###  Volume of wastewater flow

Installation
Several installation f actors should be considered befo re the type and location of a separator are chosen. If office space is leased, tenant-landlord issues may affect the type and location of a separator that can be installed. For example, a gravity unit would require the use of basement space and access to water and sewer lines. A common question of dental offices is w ho should install a separator. A licensed plumber is recommended. A licensed electrician may also be needed for systems utilizing pumps (depending upon the application). Installation may be arranged by the equipment manufacturer/distributor (depending upon local code requirements, a nd lease requirements). Table 6 presents a checklist of installation factors for dentists to consider in selecting and installing amalgam separator equipment.25 Issues Encountered with Various Field Installations Issues that have been encountered during the installation of amalgam re moval equipment include:



###  Insufficient space or access to preferred installation location (e.g., basement vs. office level, access to centralized plumbing locations); 

###  Compatibility with, and condition of, existing piping; 

###  Tenant/landlord issues; 

###  Local plumbing code interpretations; 

###  Impacts on vacuum system operation; 

###  Warranty impacts (for existing in-situ equipment); 

###  Maintenance and re pair responsibilities; 

###  Multi-chair installation requirements. Space and Utility Requirements The physical dimensions of a typical amalgam separator are 9-28 inches in height, 3-12 inches in width/diameter, and 8-24 inches in length. The preferred location for gravity separators is below grade, if possible. The preferred location for separators upstream of the vacuum system is as close as possible to the vacuum pump (to minimize vacuum impacts). Many separators do not require electric power. Some may need 110 volts of electricity for pumping wastewater. Recycling and Disposal There are a wide variety of amalgam hand ling/disposal techniques and options for recycling. Spent amalgam can be a waste or a re source, if recycled. Cl assification and handling requirements for amalgam wastes vary by state. Maintenance and Cleaning Equipment maintenance and cleaning procedures are specified by the manufacturer, and are important factors to the efficiency and eff ectiveness of amalgam separator systems. The frequency of maintenance needs to be monitored on the basis of individual office activities (e.g., number of amalgam restor ations removed daily and use of polishing compound - “prophy paste” by hygienists). Some units recommend da ily application of cleansers. Some systems require the use of special cleanin g products. Training may be n eeded for dental office staff to ensure that proper maintenance and cleaning procedures are follo wed. Records of maintenance may need to be kept as a requirement of a program.26+'	- ,*0+''+0)/,+0/*7:')*06/,0)*0*

**Installation Factors Checklist for Dentists**  Total # of operatories/chairs?  How many amalgam fillings are placed or removed per day?  How many days a week does your facility operate?  Other dental practices located within your building? - Number and type?  Is dental office space leased or owned? - If leased, what terms are included for utilities maintenance?  Are you responsible for the following activities in your building: - Equipment servicing? - Water/sewer/utilities? - Amalgam collection/recycling?  Does the separator require electrical power?  Is there access to 110V electrical power at proposed location?  Is there access to a floor drain or other plumbing to hook into?  Do you operate wet/dry cuspidors?  Can the separator be installed to operate under vacuum? (To operate without being under vacuum, the separator must be installed below the air/water separator tank check valve.) - If not, it may need to be installed 1) after the liquid-ring pump (If after liquid-ring pump, is an air/water separator necessary? An air/water separator routes the air to an outside vent, rather than into the drain line.) Or 2) at wastewater outlet of air/water separator of turbine (dry) vacuum system.  Do you operate a wet or dry vacuum system? Could an amalgam separator handle the flow of water from a wet system, and not exceed its ISO-rated maximum flow?  Is vacuum system dedicated to your office? - Is this system under warranty? If yes, is the warranty voided by third-party installations?  Is vacuum system located at office level or in the basement?  Available space adjacent to vacuum system?  Access to chair-side drain line and sewer connection location? - Is it a single connection or combined connection?  Size/material of existing sewer connection line?  What is the expected flow rate of wastewater, such as during vacuum system flushing? (To compare to an amalgam separator’s ISO-rated maximum flow.)  What is the quantity of wastewater generated on a daily basis? (To compare to the volume of amalgam separators that treat wastewater on a daily batch basis and to the capacity of the air/water separator tank used in a turbine "dry" vacuum system.)  What happens if the incoming flow exceeds ISO-rated maximum? - Does wastewater back up? - If wastewater backs up into the clinic vacuum system plumbing, will there be a problem of solids build-up in the pipes, especially if pump is on the same floor as the operatories?  Does the separator hold wastewater (by backing it up within the separator surge tank) while it continues to treat?  Does the separator allow backed up wastewater to overflow, untreated?  Is there a mechanism (e.g., flow restrictor) by which the separator will retain and slow the wastewater flow as it treats? If not, does the separator allow excess flow to pass through the separator?  What is the overall capacity of the surge tank?  What is the "working" capacity of the surge tank so the air can still pass through, without drawing (vacuuming) out wastewater that would be untreated?2= 8-	  While dentists are not the largest source of mercury to the environment, they are a contributor. Out of concern for public health, dentists have a responsibility to do their part to manage dental waste properly (Kuehne, 2002). Technology is ava ilable to significantly reduce the rate of removal of mercury from dental office wastewater, and costs are likely to decrease as technology and efficiency improve. Although pr acticing dentists are faced with a number of concerns affecting a dental office (e.g., tax la ws, requirements for empl oyee safety and health, hygienists’ union, regulations concerning privacy of patient records), they are generally willing to take the necessary steps to control merc ury releases, once they understand the problem (Suchy, 2002). The problem with dental mercury is complex. This report has attemp ted to describe many of the issues and present case studies relaying the approach, cost, results, and experience of actual programs that have been implemented. For stat e/provincial or local agencies considering implementing a dental mercury reduction program, the following steps summarize information presented in this report:

1. Involve the dental community . The local dental societ y is a good place to start. Maintaining communication with the de ntal community, along with other stakeholders who are interested in merc ury control, will be key throughout the program. 2. Identify issues and define terms . Obtain understanding and acceptance from the dental community on key issues and common terms (e.g., the definition of amalgam).

3. Decide upon the means for resolving the issues . Determine the type of approach to be taken, regulatory or voluntary, and the goal to be achieve d–narrative standard or numeric limit. Also, investigate whether feasible recycling and disposal options are available.

4. Outreach to the dental community . Educate dentists about the problem, the goal of the program, and how to participate or comply.
5. Evaluate the program . Evaluate whether the results of the program are achieving the objective and make modifi cations as necessary.
Case studies have shown thatdental mercury programs imp lemented at the local level with the support of the local dental community can be effective. However, the type of approach appropriate for a partic ular state or community will likely vary with the circumstances of each locality (e.g., number of dentists, levels of mercury discharge, local ordinances). The type of approach taken will most likely be determined in c ooperation with the dental community and/or developed through trial and error.28 -  AMSA - Association of Metropo litan Sewerage Agencies (2002) . Mercury Source Control & Pollution Prevention Program Evaluation: Fi nal Report. March 2002 (Amended July 2002). Berglund, P. (2002). Presentation at Great Lakes Binational Toxics Strategy Mercury Workgroup meeting, December 2, 2002.
Canadian Council of Ministers of the Environment (CCME). See http://www.ccme.ca/initiatives/standards.html Drummond, J.L. (2002). Presentation at Great Lakes Binational Toxics Strategy Mercury Workgroup meeting, December 2, 2002. Drummond, J.L., Cailas, M.D., Ov sey, V., Stone, M., Roddy, W.C., Francis, B.M., Babka, M.A., Perry, R.P., Toepke, T.R., Cohen, M.E., and Ralls, S.A. (1994). “Dental Waste Water: Quantification of Constituent Fractions.” Report released by University of Illinois: Chicago & Champaign-Urbana, IL, and Great Lakes Naval Dental Research Institute, Great Lakes, IL. ENVIRON International Corporation (2003). “Assessment of Merc ury in the Form of Dental Wastewater in the United States.” Prepared for the American Dental Association, Chicago, Illinois, August 12, 2003. Fan, P.L. (2002). Presentation at Great Lakes Binational Toxics Strategy Mercury Workgroup meeting, December 2, 2002. Fan, P.L., Batchu, H., Chou, H-N., Gasparac, W., Sandrik, J., Meyer, D.M. (2002). “Laboratory Evaluation of Amalgam Separators.” The Journal of the American Dental Association (JADA). May 2002. 133:577-584. Available online at http://www.ada.org/prof /pubs/jada/index.asp

. International Organization for St andardization (1999). Dental e quipment - Amalgam separators. ISO 11143. The copyrighted ISO test procedure may be obtained throug h American National Standards Institute, at www.ansi.org. (Correcti ons to the test method may be downloaded for free. Go to http://webstore.ansi.org/ansidocst ore/find.asp? and look up “amalgam separator”.) Kennedy, C.J. (2003). “Uptake and accumulati on of mercury from dental amalgam in the common goldfish.” Carassius auratus, Environmental Pollution , 121(3):321-326. King County Dental Wastewat er Discharge Fact Sheet (2003). Available online at http://dnr.metrokc.gov/wlr/indwaste/dentists.htm Krauel, R. (2002). Presentation at Great Lake s Binational Toxics Strategy Mercury Workgroup meeting, December 2, 2002.2< Kuehne, J. (2002). Presentation at Great Lake s Binational Toxics Strategy Mercury Workgroup meeting, December 2, 2002. Larson, N. (2002). Presentation at Great Lakes Binational Toxics Strategy Mercury Workgroup meeting, December 2, 2002. Linn, K. (2003). Personal communication, February 2003. Magnuson, P. (2003) Persona l communication, September 2003. Massachusetts Strategic Envirotec hnology Partnership (STEP) (Oct. 2002). McManus, K.R. (2002). Presentation at Great Lakes Binational Toxics Strategy Mercury Workgroup meeting, December 2, 2002.
Minnesota Dental Associa tion (MDA) and Metropolitan C ouncil (2003). “Re: amalgam recovery.” Minnesota Dental Association and Metr opolitan Council, St. Paul, Minnesota, March 2003. Samek, L. (2002). Presentation at Great Lakes Binational Toxi cs Strategy Mercury Workgroup meeting, December 2, 2002. Stone, M.E., Cohen, M.E., Liang, L., Pang, P. (i n press). “Determinati on of methyl mercury in dental-unit wastewater.” Dental Materials. Stone, M.E., Kuehne, J.C., Karaway, R.S., Gullett, J.M. “TCLP Analysis and Residual Mercury Levels in Dental Wastewater Lines.” Naval Dental Research Institute, U.S.A. Abstract available online at http://www.dentalmercury.com/den talmercury/Publicati ons/publications_15.html (Accessed February 2003). Stone, M.E., Pederson, E.D., Auxer, R.A., Davi s, S.L. (1999). “Line Cleanser/Disinfectant Effects on Soluble Mercury Conten t of Dental Wastewater.” Journal of Dental Research , 78:207, #814. Suchy, K. (2002). Presentation at Great Lake s Binational Toxics Strategy Mercury Workgroup meeting, December 2, 2002. Sustainable Hospitals (1998). Dental Am algam and Mercury. Available online at http://www.sustainablehospitals.org/HTML Src/IP_Merc_BMP_DentalAmalgam.html. Tuominen, T. (2002). Presentation at Great Lakes Binational Toxics Strategy Mercury Workgroup meeting, December 2, 2002. Water Environment Federation ( 1999). “Controlling Dental Facility Discharges in Wastewater.”9 Watson, P. (2002). Presentation at Great Lakes Binational Toxics Strategy Mercury Workgroup meeting, December 2, 2002. Westman, J.F., and Tuominen, T. (2000). “Amalgam Waste Manage ment - Issues and Answers.” Northwest Dentistry , March-April 2000.

$*)0*0/ )*)06//,6/+0)/, : **Subject Website** American Dental Asso ciation http ://www.ada. org American National Standards Institute http:// www.ansi. org and http://webstore.ansi.org/ansidocstore/find.asp? Canadian Council of Ministers of the Environment (Canada Wide Standard - amalgam) http://www.ccme.ca/initi atives/standards.html

Canadian Dental Association (MOU on dental amalgam) http://www.cda- adc.ca/english/news_events/news_relea ses/2002/02_18/2002.asp Kansas State University Dent al Curriculum h ttp://www.s beap.org King County’s voluntary dental program http:// www.metrokc. gov/hazwaste/pubs/studies/ King County’s mandatory dental program http://dnr.metrokc.gov/wlr/indwaste/dentists.htm Minnesota Dental Association http:// www.m ndental.org/professionals/amalgam_recove ry/ Naval Dental Research Institut e http://www. dentalmercury.com/home.html Royal College of Dental Surgeons of Ontario (Amalgam regulation and BMPs) http://www.rcdso.org Sustainable Hospitals Project http://www.sust ainablehospitals.org/HTMLSrc/IP_Merc_ BMP_DentalAmalgam.html Toronto Sewer Use By-law http://www.city.toronto.on.ca/wes/techservices/involved/ wws/nbylaw/index.htm

## APPENDIX A: **ADA BEST MANAGEMENT PRACTICES FOR AMALGAM WASTE** 7 Office of Air Quality Planning and Standards, Office of Research and Development. Mercury Study Report to Congress. Volume II: An inventory of anthropogenic mercury emissions in the United States. Washington, D.C.: Environmental Protection Agency. Publication No. EPA-452/R-97-004. December 1997, p. ES-6.

8 EPA. Major Pollutants Causing Impairment by State. Available at www.epa.gov/owow/tmdl/ 303dcaus.html. Accessed January 29, 2003. &;( #-"$ Dental Amalgam Waste: Dental amalgam waste can be recycled to help prevent the release of mercury to the environment. Following the simple suggestions outlined in this document will help protect the environment.
Concern about the effects of merc ury in the environment has incr eased over the years. Mercury in the environment is bioaccumulative, which means that it can build up in fish and cause health problems in humans and other animals that eat fi sh. Many state healthprofessionals recommend limiting fish consumption, especially for children and pregnant women. Mercury is a naturally occurring metal; however, about half of the mercury released to the environment comes from human activity. Of that amount, 53% is emitted from combustion of fuels for energy production and 34% is from the combustion of waste. 7 Sources associated with manufacturers and consumers makeup the remaining 13%, with dentistry contributing less than one percent. Some mercury released into the air eventually collects in the waterways, where it enters the food chain. As a precautionary measure, U.S. regulators typically assume that all or most of the mercury released into the air or surface water may accumulate in fish. As of 2000, the U.S. EPA lists more than 43,971 miles (covering 3,426,244 acres) of rivers and streams in the U.S. as "impaired" because of the presence of mercury. 8 Although mercury in the form of dental amalgam is very stable, amalgam should not be disposed of in the garbage, infectious waste "red bag, " or sharps container. Amalgam also should not be rinsed down the drain. These cautions are important because some communities incinerate municipal garbage, medical waste, and sludge from wastewater treatment plants. If amalgam waste ends up in one of these in cinerated waste streams, the mercury can be released to the environment due to the extremely high temper atures used in the incineration process. Increasingly, local communities are enacting restrictions on the incineration of wastes containing mercury. The good news is that amalgam waste, kept sepa rate from other waste, can be safely recycled. The mercury can be recovered from amalgam wastes through a distillation process and reused in new products. The ADA strongly recommends recy cling as a best management practice for dental offices. The following information demonstrates how to manage and recycle dental amalgam waste to help protect the environment.&; The ADA recommends against the use of bulk elemental mercury, also referred to as liquid or raw mercury, for use in th e dental office. Since 1984, the ADA has recommended use of precapsulated amalgam alloy. If you still have bulk elementa l mercury in the office, you should recycle it. Check with a licensed recycler to determine wh ether they will accept bulk mercury. Do not pour bulk elemental mercury waste in the garbag e, red bag or down the drain. You also should check with your state regulatory ag ency and municipality to find out if a bulk mercury collection program is available. Such bulk mercury collection programs provide an easy way to dispose of bulk mercury. Types of Amalgam Wastes



###  Non-contact amalgam (scrap) is excess mix leftover at the end of a dental procedure. Many recyclers will buy this clean scrap. 

###  Contact amalgam is amalgam that has been in c ontact with the patient. Examples are extracted teeth with amalgam restorations, carving scrap collected at chair side, and amalgam captured by chair side traps, filters, or screens. 

###  Chair side traps capture amalgam waste during amalgam placement or removal procedures (traps from dental units dedicated strictly to hygiene may be placed in the regular garbage). 

###  Vacuum pump filters or traps contain amalgam sludge and water. Some recyclers will accept whole filters, while others will re quire special handling of this material. 

###  Amalgam sludge is the mixture of liquid and solid material collected within vacuum pump filters or other amalgam capture devices. 

###  Empty amalgam capsules are the individually dosed c ontainers left over after mixing precapsulated dental amalgam.

Steps for Recycling Amalgam Waste 1. Amalgam waste may be mixed with body fl uids, such as saliva, or other potentially infectious material, so use personal protective equipment such as utility gloves, masks, and protective eyewear when handling it. 2. Contact an amalgam waste r ecycler about any special re quirements that may exist in your area for collecting, storing and transporting amalgam waste. If you need to find a recycler, check with your city, county or local waste authority to see whether they have an amalgam waste recycling program. 3. Store amalgam waste in a covered plastic container labeled "Amalgam for Recycling" or as directed by your recycler. Consider keeping different types (e.g., c ontact and non-contact) of amalgam wastes in separate container—talk to your recycler about any advantages in doing so.&;2 Questions to Ask Your Amalgam Waste Recycler Below is a list of questions you may want to ask your amalgam waste recycler. Note that not all recycling companies accept every type of amalgam waste, and the services offered by recyclers vary widely. The ADA recommends that you contacta recycler before recovering amalgam and ask about any specific handling instructions th e recycler may have. Importantly, select a reputable company that complies with applicab le federal and state la w and provides adequate indemnification for its acts and omissions. Ask Your Recycler ...



###  What kind of amalgam waste do you accept? 

###  Do your services include pick up of am algam waste from dental offices? If not, can amalgam waste be shipped to you? 

###  Do you provide packaging for storage, pick up or shipping of amalgam waste? 

###  If packaging is not provided, how should the waste be packaged? 

###  What types of waste can be packaged together? 

###  Do you accept whole filters from the vacuum pump for recycling? 

###  Is disinfection require d for amalgam waste? 

###  How much do your services cost? 

###  Do you pay for clean non- contact amalgam (scrap)? 

###  Do you accept extracted teeth with amalgam restorations? 

###  Does your company have an EPA or applicable state license? 

###  Does the company use the proper forms required by the EPA and state agencies?&;9 Best Management Practices for Amalgam Waste

DO DON’T Do use precapsulated alloys Don’tuse bulk mercury Do recycle used disposable amalgam capsules Don’tput used disposable amalgam capsules in biohazard containers, inf ectious waste containers (red bags) or regular garbage Do salvage, store and recycle non-contact amalgam (scrap amalgam) Don’tput non-contact amalgam waste in biohazard containers, inf ectious waste containers (red bags) or regular garbage Do salvage (contact) amalgam pieces from restorations after removal and recycle the amalgam waste Don’tput contact amalgam waste in biohazard containers, infectious wa ste containers (red bags) or regular garbage Do use chair-side traps to retain amalgam and recycle the content Don’trinse chair-side traps containing amalgam over drains or sinks Do recycle contents retained by the vacuum pump

filter or other amalgam collection device, if they contain amalgam Don’trinse vacuum pump filters containing amalgam or other amalgam collection devices over drains or sinks Do appropriately disinfectextracted teeth that contain amalgam restorations (e.g., 10 minutes in a 1:10 bleach-to-water solution) and recycle along with the chair side trap waste (Note: Confirm with your recycler that they will accept extracted teeth with amalgam restorations) Don’tdispose of extractedteeth that contain amalgam restorations in biohazard containers, infectious waste containers (red bags) or regular garbage

Do manage amalgam waste through recycling as much as possible Don’tflush amalgam waste down the drain or toilet&;5 Practical Guide to Integratin g BMPs Into Your Practice
Non-contact (scrap) amalgam

 Place non-contact, scrap amalgam in wide-mout hed, airtight container that is marked "Non-contact Amalgam Waste for Recycling."  Make sure the container lid is well sealed. Amalgam capsules

 After mixing amalgam, place the empty capsules in a wide-mouthed, airtight container that is marked "Amalgam Capsule Waste for Recycling."  Capsules that cannot be emptied should lik ewise be placed in a wide-mouthed, airtight container that is marked "Amalgam Capsule Waste for Recycling."  Make sure the container lid is well sealed.  When the container is full, send it to a recycler. Disposable chair-side traps

 Open the chair-side unit to expose the trap.  Remove the trap and place it directly into a wi de-mouthed, airtight container that is marked "Contact Amalgam Waste for Recycling."  Make sure the container lid is well sealed.  When the container is full, send it to a recycler.  Traps from dental units dedicated strictly to hygiene may be placed in with the regular garbage. Reusable chair-side traps

 Open the chair-side unit to expose the trap.  Remove the trap and empty the contents into a wide-mouthed, airtight c ontainer that is marked "Contact Amalgam Waste for Recycling."  Make sure the container lid is well sealed.  When the container is full, send it to a recycler.  Replace the trap into the chair-side unit (Do not rinse the trap under running water as this could introduce dental amalgam into the waste stream. Vacuum pump filters

 Change the filter according to the manufactu rer’s recommended schedule. Note: The following instructions assume that your re cycler will accept whole filters; some recyclers require different handling of this material , so check with your recycler first.  Remove the filter. While holding the filter over a tray or other container that can catch any spills, decant as much of the liquid as possibl e without losing any visible amalgam. The decanted amalgam-free liquid can be rinsed down the drain.  Put the lid on the filter and place the sealed container in the box in which it was originally shipped. When the box is full, the filters should be recycled.&;6 Additional Resources "Dental Mercury Hygiene Recommendations" are available through the ADA Division of Science. These recommendations were published in the Journal of the Americ an Dental Association (July 1999) and also are availabl e to ADA members online at http://www.ada.org/members/pubs/jada/reports/mercury.html

## APPENDIX B: **NEORSD ADMINISTRATIVE ORDER AND BEST MANAGEMENT PRACTICES** ";( #"-  "

Administrative Order Issued to [Dental Care Practitioner]
In accordance with Section 2.0603 of the North east Ohio Regional Sewer District (NEORSD) Code of Regulations : [Dental Care Practitioner] [Address] [City, State, Zip Code] Administrative Order No. 8021-SEQ

This Administrative Order grants to [Dental Care Practitioner] the authority to discharge dental wastewater from the above iden tified facility into the NEORSD ’s sewerage collection and treatment system. This authority is granted inaccordance with the conditions set forth in this Administrative Order. All di scharges from the above-mentione d practice, requirements, and reports relating thereto shall be in accordan ce with the terms and the conditions of this Administrative Order. Compliance with this Order does not relieve [Dental Care Practitioner] of the obligation to comply with any and all applicable regulations, sta ndards, requirements, or laws that may become effective during the term of this Administrative Order. All dischargers to the NEORSD sewerage system must comply with all applicable laws, regulations, standards, and re quirements contained in the NEORSD Code of Regulations

. Following is the local limit for mercury under Section 1.0915 of the NEORSD Code of Regulations : “Except where application of the most sens itive analytical method approved under 40 CFR Part 136 for mercury in wastewater demonstrates to the District’s satisfaction that no mercury is detectable in the user’s discharge to the System, all Industrial Users are, for the purpose of this section, sources of mercury. All Industrial Users that are s ources of mercury shall implement Best Management Practices (BMP s), as defined under section 1.0203 of this Title of the Code of Regulations , to minimize discharges of mercury to the System. Ce rtain Industrial Users and/or classes of Industrial Users identif ied by the District as signif icant sources of mercury shall comply with District-issued administrative orders requiring submittal and implementation of BMP plans for mercury discharge minimization. Any Industrial User that is a source of mercury failing to implement BMPs in a manner and to an extent satisfactory to the District and/or failing to fully comply with requirements in an administrative order shall be subject to charges as indicated under Section 1.0924 and/or refusal of service as indi cated under Section 1.0907.”"; Following is the definition of an Industrial User under Section 1.0225 of the NEORSD Code of Regulations : “ ‘Industrial User ’ – shall mean a discharger of any liqui d, solid, or gaseous substance or form of energy, or combination thereof, resulting from any process of i ndustrial, commercial, governmental, and institutional concerns, manufacturing, business, trade or research, including the development, recovery and pr ocessing of natural resources, or from sources other than those described in Section 1.0217 (Domestic Sewage).” Following is the definition of best manageme nt practices (BMPs) under Section 1.0203 of the NEORSD Code of Regulations : “ ‘Best Management Practice (BMP) ’ – Methods determined by th e Director to be the most effective, practical means of preventing or reducing pollution, including but not limited to: substitution of materials; reform ulation or redesign of produc ts; modification of equipment, facilities, technology, pr ocesses, and procedures; and impr ovement in manage ment, inventory control, materials handling or general operation of a facility.” Administrative Orders are issued to dental care practitioners as they have been determined by the NEORSD to be a class of Industrial Users thatis a significant source of mercury into the sewerage system. Pursuant to Secti on 1.0915 of the NEORSD Code of Regulations , offices employed in practicing dental care are required to submit and implement a BMP plan as described below.

Part One – Process/Operational Description

A. [Dental Care Practitioner] is employed in practicing de ntal care. The discharge from this process is regulated by the NEORSD Code of Regulations

. Part Two – BMPs A. The goal of the BMP plan is to maintain wastewater effluent total mercury concentrations below 0.2 nanograms per liter (p arts per trillion). Any fac ility discharging mercury into the NEORSD’s sewerage system shall make reasonable progress in developing, incorporating, and continuous ly improving BMPs to minimize the facility’s discharge of mercury. During the term of this Administrative Order, implemented BMPs shall not be altered in any manner that would be expected to result in a net increase in the overall quantity of mercury entering the sewerage system. The NEORSD must be notified prior to any alteration of implemented BMPs that has not been specified in the approved BMP plan. By December 31, 2002, [Dental Care Practitioner] shall develop a BMP plan and submit it to the NEORSD for review and approval. The obj ective of this plan is to identify pollution prevention opportunities and imp lement those opportunities th at are technically and economically feasible. The plan shall include the following.";2 1. A list of individuals responsible for de veloping, implementing, and practicing under the BMP plan. The list must include th e name of one individual designated as primarily responsible. 2. An inventory of potential sources of mercury. The inventory shall include a description of each potential source. 3. A description of any current and past BM Ps for mercury and any information on the effectiveness of such BMPs. 4. Identification and any technical/ economical evaluation of new BMPs. 5. A schedule for implementation of economically feasible BMPs. 6. Any methods used for measuring progre ss towards the BMP goal and updating the BMP plan. Required BMPs and examples of other po ssible BMPs are listed in the Appendix A. C. [Dental Care Practitioner] will be subject to periodic, unannounced monitoring by the NEORSD and will be responsible fo r reimbursing the NEORSD for certain expenses associated with this monitoring. Part Three – Reporting Requirements A. By March 1 of 2003 and each year thereafter, [Dental Care Practitioner] shall submit an annual report to the NEORSD. The annual report must include: 1. Any BMP plan monitoring results for the year; 2. An updated inventory of pot ential sources of mercury; 3. A summary of any information indicating the effectiveness of all BMPs implemented to meet the BMP plan goal; 4. Any updates to the BMP plan; 5. Copies of any corresponden ce that indicates compliance, including but not limited to hazardous waste hauling mani fests or bills of lading. B. [Dental Care Practitioner] must notify the NEORSD immediately upon occurrence of an accidental discharge of merc ury-containing material or an y other slugload or spill that has potential to enter the NEORSD’s sewerage system. Notifications are to be made to the District by telephone at (216) 641-6000, Monday through Friday from 8:00 a.m. until 4:30 p.m., or at any other time by telephone at (216) 641-3200. C. [Dental Care Practitioner] must report any outage or ma lfunction of any pretreatment system for mercury removal (e.g., amalgam traps, filters, screens, and/or separators) within twelve (12) hour s of discovery of suchoutages or malfunction. Part Four – Violation Charges A. Any failure to comply with this Administrative Order and/or the provisions set forth in the NEORSD Code of Regulations may result in charges and/ or damages as stipulated necessary by the NEORSD. Part Five – Special Conditions A. Reopener Clause 1. This Order may be reopene d and modified to incorpor ate any new and/or revised requirements contained in the NEORSD Code of Regulations.";9 2. This Order may be reopened a nd modified to incorporate an y new or revised requirements resulting from the District’s reevaluation of local limits or to ensure POTW compliance with applicable sludge mana gement requirements promul gated by EPA (40 CFR 503). B. Compliance Schedule 1. [Dental Care Practitioner] shall contact the NEORSD within thirty (30) days of receipt of this correspondence to negotiate any modi fications to the enclosed Administrative Order. Pursuant to Section 5.1 of the NEORSD Code of Regulations , “Rules and Procedure for Administrative Determinations”; failure to petition for reconsideration of the Administrative Order within the allotted 30 days is deemed a waiver by the receiver of any right to challenge for modification of the terms of this Administrative Order. 2. A complete BMP plan must be sub mitted to the NEORSD by December 31, 2002. 3. Implementation of the BMP plan should begin as soon as possible but must be in place by December 31, 2002.

Noncompliance with any term or condition of this Administrative Order shall constitute a violation of the NEORSD Code of Regulations . This Administrative Order shall become effective on April 1, 2002 and sh all expire on April 1, 2007. Upon expiration, the provisions of this Administrative Order shall remain in effect until a new Order is effective. The NEORSD may reevaluate the fac ility prior to the expiration date of this Order; an updated Order may be issued prio r to the expiration date. Issued this 27th day of March, 2002. Respectfully yours,

Richard N. Connelly Superintendent of Environmental Services Northeast Ohio Regional Sewer District

DENTAO 2/12/02";5 Best Management Practices (“BMPs”) for Minimization of Mercury Discharges from Dental Offices to the Sewerage System

Prepared by the Northeast Ohio Regional Sewer District in Cooperation with Representatives of the Ohio Dental Association and the Greater Cleveland Dental Society

Page 1 of 7

By making a check mark in the appropriate boxes (to indicate which, if any, of the recommended BMPs will be impl emented at your office) a nd providing the requested information below, a signed copy of this do cument may be submitted to the Northeast Ohio Regional Sewer District (“NEOR SD”) as the required BMP Plan for this office. Additional pages may be attached, as necessary, to supplement this document. (Send a request to LinnK@neorsd.org if you would prefer to be e-maile d a Microsoft Word version of this document.)

# If the practice at this office does not handle dental amalgam, you may make a check mark in this box and proceed directly to page 7 of this document. ( If the practice at this office handles dental amal gam in any form, such as extractions of amalgam or extractions of teeth that contain amalgam, do not make a check mark in this box .)

Mandatory BMPs 

#  Eliminate all use of bulk elemental mercury (also referred to as liquid or raw mercury). Use only precapsulated dental amalgam. Any bulk elemental mercury must be recycled or hauled away as hazardous waste. It must never be poured into the regular trash, in with infectious waste (red bag), or down the drain. (You may contact NEORSD Mercury Prog ram staff at 216-641-6000 or the Ohio Dental Association at 614-486-2700 for in formation on recycling bulk elemental mercury or dental amalgam.) 

#  Limit the amount of amalgam used to the smallest appropriate size for each restoration. Keep a variety of amalgam capsule sizes on hand to more closely match the amount triturated to the amount needed in the restoration.";6 

#  Change or clean chairside amalgam traps frequently. Flush the vacuum system before changing the chairside trap. 

#  Change vacuum pump filters and screens at least once per month or as directed by the manufacturer. 

#  All amalgam waste must be either recycl ed (preferred method) or hauled away as hazardous waste (acceptable a lternative). Included are: Non-contact amalgam (scrap); Contact amalgam (e.g., extracted teeth containing amalgam); Amalgam/sludge captured by chairside traps, vacuum pump filters, screens, and other devices; Used amalgam capsules that visibly contain any mercury; Leaking or unusable amalgam capsules. Amalgam waste must never be put in the regular trash, put in with infectious waste (red bag), or flushed down the drain. Amalgam-containing traps, filters, or screens must never be rinsed over drains or sinks. 

#  Store amalgam waste in covered, segregat ed, and clearly labe led airtight plastic containers or as direct ed by your recycler. 

#  Maintain a log of amalgam waste generation and recycling/disposal. Documentation of all amalgam waste recy cling and disposal must be obtained from your recycler or hazardous waste hauler, kept on file, a nd made available to the NEORSD upon request. 

#  Train all staff that handles or may handle mercury-containing material in its proper use and disposal.

Recommended BMPs

# Use, when appropriate, merc ury-free alternatives to amalgam (e.g., gold, ceramic, porcelain, composites, polymers, gla ss ionomers, cold silver, gallium).";=

# Clean or replace under-sink traps and sumps, taking care to avoid spillage of the contents from plumbing parts. Remove sludge that may contain mercury, and have it recycled or hauled away as hazardous waste.

# Install clear plastic, easily removable unde r-sink P-traps, and have the contents recycled or hauled away as hazardous waste if they may contain inadvertently spilled mercury-containing material.

# Use disposable chairside amalgam traps inst ead of reusable traps in your cuspidor and vacuum system, and have the disposab le traps recycled or hauled away as hazardous waste.

# Maximize the use of the high-speed suc tion (vacuum) system, because it captures more of the amalgam waste than does the coarse screen in a cuspidor.

# During amalgam restoration/extraction procedures, remove wet cuspidors from service and rely solely upon the high-sp eed suction (vacuum) system to remove debris and saliva.

# Avoid using sodium hypochlorite (bleach) to disinfect vacuum lines, because it dissolves mercury out of amalgam.

# Be knowledgeable about amal gam separators employing enhanced sedimentation, fine particle filtration, and/or other technologies. Install and pr operly maintain such technologies that are determin ed to be feasible and effective.

# Obtain mercury spill kits, place them in appropriate easy-to- access locations, andimmediately use them as directed by the manufacturer for any spill of mercurycontaining material. All spilled mercury-containing material must be recycled or hauled away as hazardous waste.";8

# Implement a program to have mercury-c ontaining thermostats, switches, and fluorescent light bulbs recycled when they are replaced. Thermostats and switches should be replaced withmercury-free alternatives.

# Describe below any additional BMPs for mercury discharge minimization that you may have identified and plan to implement.

Please provide the following information to the best of your ability.

1. List the individuals, including all the dental care practitioners at your office, who are responsible for developing, implementing, and practicing under this BMP plan, and designate one individual who has the primary responsibility for it:



### 2. List and describe all identified potential sources of mercury or mercury-containing materials that could enter the sewerage system from this office:



### 3. Describe any BMPs that you may have implemented in the past and/or may be currently implementing for mercury disc harge minimization. (See previ ous pages of this document for examples.) Also, pleas e provide any information th at you may have obtained regarding the effectiveness of the BMPs:";< 

### 4. Provide information from any technical/ economical evaluation that you may have performed on BMPs for mercury discharge minimization:



### 5. Provide a schedule for implementation of the BMPs that you have indicated will be implemented for mercury discharge minimization at this office. Implementation of all mandatory BMPs should begin as soon as possible and must begin no later than December 31, 2002.



### 6. Describe any methods that y ou may have identified for m easuring progress toward the BMP Plan goal and updating this BMP Plan (e.g., documenting increased utilization of mercury-free alternatives, researching new BMPs, etc.):";( Your Name: Mailing Address:

Office Address (if differen t from Mailing Address):

Telephone Number:

________________________________________________ __________________ Your Signature Date

If this document is to serve as your required BMP Plan for mercury discharge minimization, send one completed copy of it fo r each office at which you practice no later than December 31, 2002 to the address below: Northeast Ohio Regional Sewer District 4747 East 49 thStreet Cuyahoga Heights, OH 44125-1011 Attention: Mercury Program

DENTBMPs 2/12/03

## APPENDIX C: **OTHER DENTAL MERCURY PROGRAMS**.;( #-! Los Angeles, California The City of Los Angeles, and six other cities who contract with Los Angeles for wastewater treatment, have a formal regulatory program for dental offices . This program requires dental offices to comply with specific BMPs, but it does not require amalgam separators. Point of Contact : Teresa Pichay, California Dental Association (209) 257-1935, TeresaP@cda.org

Massachusetts
The Massachusetts Executive Office of Environmen tal Affairs is performing a study of ISO test and available separators. There is cu rrently no regulatory plan in effect. Point of Contact : Charles Bering (617) 788-2309, Charles.Bering@mwra.state.ma.us Minneapolis & St. Paul Metropolitan Area and the State of Minnesota The Metropolitan Council (Council) and the Minnesota Dental Association (MDA) have implemented a voluntary Amalgam Recovery Program in the Minneapolis-St. Paul metropolitan area. Clinics participating in the program are issued a “Certifi cate of Compliance” for installing an approved amalgam separator and properly managing amalgam wast es generated by the clinic. Approved separators must remove 99% of the amalgam (by ISO testing). Clinics maintain certification by properly operating and maintaining the separator, implementing Best Management Practices, and submitting a statemen t annually to the Council certifying that the separator is in place, operating, and that “Bes t Management Practices” are being implemented. The MDA is extending this program beyond the Council's metropolita n area and promoting separator installation to all of Minnesota. Prior to imple menting the program, the Council and the MDA completed two dental mercury studies which showed that amalgam separators are effective at removing amalgam from dental office wastewater and that the use of amalgam separators will reduce the amount of mercury present in wastew ater treatment plant sludge. More information about the amalgam recovery pr ogram and the studies can be obtained from the point of contact. Point of Contact : Peter Berglund, Metropo litan Council Environmental Services (651) 602-4708; peter.berglund@ metc.state.mn.us New Hampshire The state passed legislation requiri ng its environmental agency to promulgate regulations for all dental offices. This is exp ected to be accomplished in 2003.

New York Effective March 16, 2003, the State of New Yo rk added a law that bans the use of non-encapsulated elemental mercury in dental offices and requi res dentists to recycle any mercury or dental amalgam waste generated in their offices in accordance with regulations.; established by the New York St ate Department of Environmenta l Conservation (DEC). DEC is in the process of developing regu lations to assist dentists with implementation of this law. More information can be found at http://www.dec.st ate.ny.us/website/dsh m/redrecy/mercdent.htm Point of Contact : Jim Honan, Environmen tal Program Specialist, NYSDEC, 625 Broadway, Albany, NY 12233; (518) 402-8704; jphonan@gw.dec.state.ny.us Richmond, California, San Francisco Bay area Nine dentists in the service area must comp ly with a 5 ppb discharge limit. Dentists have worked cooperatively with the city of Richmond fo r the past 2-3 years. All dentists have been cited for violating the limit at least once, but the fines have been waived. The city has tried numerous methods to reduce the me rcury discharge. The best results were achieved when a dentist implemented BMPs and installed a separator, althoug h the local discharge limit was still exceeded. Point of Contact : Teresa Pichay, California Dental Association (209) 257-1935; TeresaP@cda.org U.S. Navy The U.S. Navy is in the process of installing amalgam separators in all dental facilities. Installed systems remove particulate and “dissolved mercury.” Separators will be installed in all U.S. and overseas dental treatment facilities. The program is managed by the Naval Dental Research Institute (NDRI) with funding from the De partment of Defens e, Health Affairs. Wichita, Kansas Wichita has a metropolitan area of 500,000 in southeast Kansas. There are 200 dental clinics in the metro area, 150 of which are general practice dentists (thought to handle amalgam). Phase 1 of a regulation passed by the city requires installation of technology greater than already in an office by October 2001. If a 50 percent reducti on to the wastewater treatment plant is not obtained by June 2003, then Phase 2 will be implemented. Phase 2 requires the mandatory installation of ISO 11143 certified se parators. The city maintains a list of approved separators. Each dental clinic samples wa stewater annually and submits an annual self-monitoring report. The city also inspects and sample s clinics on an annual basis. Sludge from the city’s wastewater treatment plant is land-applied. Points of Contact : Jamie Belden (316) 303-8775 or Rebecca “Becky” Gagnon (316) 303-9900

The Pollution Prevention Institute at Kansas State University has undertaken a mercury educational effort. Through this effort, an am algam waste fact sheet has been developed and a curriculum presented to dental schools and to hygiene and dental assistance programs. Point of Contact : Nancy Larson (800) 578-8898 or Nlarson@ksu.edu.

## APPENDIX D: **AMALGAM SEPARATORS APPROVED BY KING COUNTY**;( #- "%=  9A
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