Dental Facility Inspection Form, Last updated December 29, 2010

Endodontics: the branch of dentistry that deals with diseases of the dental pulp or nerves

Periodontics: the branch of dentistry concerned with the treatment of diseases of the gums and other periodontal tissues

Orthodontics: the area of dentistry concerned with the prevention and correction of irregularities of the teeth – straightening teeth

Compliance: Yes No SEQ # _____

Sample Point: Yes No

Supervisor’s Review ________

    	 
   
 
 
   
	     
	 	   


   	  
	 
  
     
    

Visit Date: _______________________Date of BMP Plan: ______________________________

WQIS Investigators: _______________________ Date of Most Recent Annual Report: __________________

NOTE: Annual Reports are due to NEORSD by March 1

st

Each Year

I. GENERAL DENTAL FACILITY INFORMATION

Name of Practice: ____________________________________________________________________

Type of Practice: General Pediatric Endodontics Periodontics Orthodontics Other: ________

No. of Dentists: ___ No. of Hygienists: ___ No. of Chairs: ___ No. of Emp. ____________

Name(s) of Dentist(s): _________________________________________________________________

Facility Address: _____________________________________________________________________

Business Telephone No.: ________________________ Fax No.: ___________________________

Email: ______________________________________________________________________________

Name of Facility Contact: __________________________ Title: _____________________________

Name of Property Owner: __________________________ Owner's Phone No.: ______________________

Customary Facility Hours:

Day/Time Sun Mon Tues Wed Thur Fri Sat

Start

End

Number of years any dental facility has existed at this location: _________________________________

(this is to determine the age of the plumbing; if >20 yrs. old, chances are good that bulk Hg was used)

Water Account No.: _______________________ ;Consumption: _____________MCF /year*

* - Complete Before Inspection

Does Account Include other Uses ____________, or Users _____________________________________

Remarks:____________________________________________________________________________

____________________________________________________________________________________
NEORSD Dental Facility Inspection Form

II. AMALGAM USE AND WASTE MANAGEMENT PRACTICES:

DOES THIS DENTAL FACILITY  AMALGAM FILLINGS,  	 AMALGAM FILLINGS AND/OR

EXTRACT TEETH CONTAINING AMALGAM FILLINGS? : Yes No

A. Who takes care of the amalgam waste in the office? (If multiple employees, other than the Dr. or 1

assistant, yearly training should be in place and needs to be documented)

Describe Training: ______________________________________________________________

If more than one employee is responsible, is any documentation of training available?

• No - recommend that they document training and submit copy with annual report.

B. Amalgam use in the facility: 

• Average number of amalgams placed at this facility __________ per day, week, month, or year

• What sizes of amalgam capsules are typically used? : 

Single Spill Double Spill Triple Spill N/A

• Average number of amalgams removed: ___________ per day, week, month, or year

* including teeth extracted with amalgam fillings

• Are these amalgam use numbers estimates by staff or based on records ?

• Where and how are amalgam capsules stored?

_________________________________________________________________

• Has mercury/amalgam ever been spilled? : Yes No

o If yes, how was it cleaned up?

C. Management of amalgam waste in facility (COMPLIANCE IS DETERMINED HERE):

R- Recycled/Bucket

D- Disposable

X- Reusable

Amalgam

Scrap 

Used

Chairside

Traps

Used Vacuum

Filter or

Screen

Used 

Capsules

Extracted Teeth w/

amalgam fillings

Contents N/A

Container (trap or

screen or capsule)

N/A N/A

• Name and address of waste amalgam recycling contractor:

__________________________________________________________________________

• How often does this recycler pick up waste amalgam?: ______________________________

• Request copies of the recyclers manifests: Yes No

Copy Obtained During Visit? _____________ Or, Copy Mailed within 30 Days? ______________

Remarks: ________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

• Yes - obtain a copy or ask that it is mailed to WQIS;
NEORSD Dental Facility Inspection Form

D. Ultrasonic Instrument Cleaning Baths

Number of ultrasonic baths: ________________ Total volume (gallons): ___________________

How often are the baths changed? __________________________

How are the spent baths managed? _________________________

III. DESCRIPTION OF OPERATORY EQUIPMENT

A. Cuspidor (porcelain sink at chairside)

Type of cuspidor used for those chairs where amalgam is placed or removed:

Not applicable – no cuspidor or cuspidor is only used for hygiene

Wet Cuspidor w/ Continuous Flow

Wet Cuspidor w/ Flush Flow

Trap in Cuspidor Bowl

Is trap disposable? recycled? Or reusable?

(the contents of this trap may be removed with the hi-speed vac or manually removed and put into recycling container)

B. Vacuum System Equipment

Type of vacuum system used for those chairs where amalgam is placed or removed:

Saliva Remover (Low Volume) High Speed Suction Tip Other ______________

This system is a: Local Vacuum Unit in Operatory

Central Vacuum Unit

Is there a chairside trap in the operatory vacuum line?: Yes No

Screen Size: ~1.0mm ____other

Type of vacuum pump: Air Cooled Water Cooled

If water-cooled, is it: Recycled Water Fresh (Not Recycled) Water

Does the vacuum pump have an in-line filter?: Yes ________ microns No

Does vacuum system include an air-water separator tank?: Yes No

Volume of the air-water separator: _______ gallons

C. Amalgam Separator Equipment

Is an Amalgam Separator used at this facility?: Yes No

If yes, when was it installed: __________________________________________________

Specify model and vendor: _____________________________________________

Is model 99% Efficient? Yes No

Is model ISO 11143 Certified? Yes No

IF NO, THE FACILITY MUST INSTALL ONE TO BE IN COMPLIANCE WITH NEORSD REGULATIONS
NEORSD Dental Facility Inspection Form

IV. LINE DISINFECTANTS

What line disinfectant is currently used at this facility? ___________________________

Does disinfectant contain sodium hypochlorite (bleach)? Yes No

Inspectors Note: Based on Naval Dental Research Laboratory research, the following line cleaners do not

appear to dissolve Hg from amalgam and are alternative disinfectants to bleach:

Adec1CX Gobble Plus Sani-Treet VAC-U-EZ

BLU-TAB Green and Clean SRG VAC-U-SOL

Cavicide Lines Stay –Clean Vigilance Enzymatic

ENZYMATIC Maxi-Evac Super Dent

E-Vac ProE-Vac SUV

Evacuation Cleaner Purevac Turbo Vac Line Flush

EZ-Zyme Sani-Treet Plus Vacu Cleanse

NEORSD DOES NOT RECOMMEND OR ENDORSE ANY OF THESE PRODUCTS

V. DENTAL FACILITY LAYOUT

Facility Layout Drawing: Show a sketch of the dental facility with emphasis on operatories, vacuum

system, and a location(s) where dental wastewater samples can be prior to discharge to the sanitary

sewer. Indicate the approximate scale of the drawing. Alternatively, a drawing of the facility layout

furnished by the facility may be attached.

NEORSD Dental Facility Inspection Form

VI. Notes and Observations (Attach Additional Sheets as Needed)

A. Have any wastewater samples been collected and analyzed for Hg?

• Yes No

• If yes, Analytical Method: 1631 or 245

• If yes, request copy of analysis.

B. Misc. Facility Information

• Sampling Location: ____________________________

• Unique Sampling Opportunity? __________________

• Water Meter? _________________________________

• Photographs Taken? Yes No

C. List any unique features or processes at this dental facility:

______________________________________________________________

______________________________________________________________

D. Comments made by the staff from this dental facility.

______________________________________________________________

______________________________________________________________

E. Comments/Follow-Up Actions

______________________________________________________________

______________________________________________________________

WQIS Investigators: __________________________________

Initials: __________ Date: _________________

Time In: ______________ Time Out: _____________

Signature: ______________

Report Continued on Additional Pages: Yes No

Is Office In Compliance? Yes No