# Dental Mercury Amalgam Waste Management White Paper

April 2008 QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUSThe Quicksilver Caucus (QSC) is a coalition of State associations
formed to address and resolve hea lth and environmental problems resulting from the release of mercury to the environment. The membership of the QSC includes the Environmenta l Council of the States, the Association of State and Territorial Soli d Waste Management Officials, the
Association of State and Interstate Water Pollution Control Administrators, the Association of State Dri nking Water Administrators, the National Association of Clean Air Ag encies, and the National Pollution
Prevention Roundtable.

The QSC would like to acknowledge the following organizations for providing technical expertise to the QSC on this paper: Interstate Mercury Education and Reduction Clearinghouse, and the Metropolitan
Council Environmental Services.

The Quicksilver Caucus members de veloped this document under Cooperative Agreement Number X5 83227101, awarded by the United States Environmental Protection Agency (US EPA).

# Dental Mercury Amalgam Waste Management White Paper1 DENTAL MERCURY AMALGAM WASTE MANAGEMENT 

# Dental Mercury Amalgam Waste Management White Paper

Executive Summary

This paper provides information to assist states in considering how to reduce sources of dental mercury amalgam released to the environment from the dental sector. Wh ile dentists have reported a downward trend in the us e of mercury amalgam for dental restoration for a variety of reasons, there are data being repor ted which demonstrates this reduc tion is rather minimal. Regardless, mercury from dental amalgam is a majo r source of controllable mercury released to the environment and likely will remain a significant concern into the future.

This paper focuses on achieving major reduction of mercury releases th rough the use of amalgam separators as the preferred best management pr actice. It examines issues related to the installation and use of amalgam separators incl uding common features of dental amalgam programs, lessons learned from exis ting local and state programs, and recommendations for future action. Case studies of state and local programs which were the basis for much of the discussion in this paper are available in a separate document, “Case Studies of Five Dental Mercury Amalgam Separator Programs”.

Some common features of the de ntal amalgam programs include:

• Using local or regional programs in order to stimulate state programs;

• Initially being voluntary but la ter evolving into mandatory;

• Needing to determine which specific se parators meet program requirements;

• Requiring dental practices to use best manageme nt practices in additi on to separa tor installation; and

• Needing to consider which, if any, specialty de ntal practices should be exempt from amalgam separator requirements.

In addition to providing information on common f eatures of these programs, the paper includes lessons learned related to the following issues:

• Amalgam separator selection

• Operation and maintenance of amalgam separators

• Communication and program implementation

Beyond providing information on lessons learned a nd common features of some existing dental mercury amalgam programs, this paper identifie s some recommendations for future action related to amalgam management such as the need for education of dental practice employees,
concerns about air emissions that result from am algam use, and the need to address legacy mercury issues in dental office plumbing. ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUSDENTAL MERCURY AMALGAM WASTE MANAGEMENT 

## Introduction

Background

In November 2006, the Quicksilver Caucus (Q SC) published a Mercury-Added Products White Paper that identified several sectors, 1 including dental c linics, where significant advances could be made in the reduction of use of and impr oved management of mercury. The recommendation to advance opportunities to re duce mercury releases in the de ntal sector gathered further momentum at the May 2007 meeting of state mercury policymakers in Madison, Wisconsin. There was particular interest in having QSC member associations and state agencies share information that would strengthen states’ capacity to reduce sources of dental mercury amalgam released to the environment. As a first step in addressing the dental sector, the QSC has developed this white paper to share approaches adopt ed by state and local governments when working to reduce mercury releases and to provide a summary of key lessons learned in some of these programs.

This paper provides an overview of the use ofdental amalgam, available non-mercury alternative restorative materials, information on am algam separators, common components of some dental mercury amalgam separator programs, a su mmary of lessons learned from some existing state and local government programs from around the United States, and recommendations for
future action.

Use of Dental Mercury Amalgam

Mercury comprises by weight appr oximately half of the metals used in common dental amalgam. Dental mercury amalgam has been regularly used in the treatment of cavities because it is easy to work with, durable, and has been viewed as cost effective

. While years ago it was standard practice for dentists to mix their own amal gam, this has been almost universally replaced by pre-measured and sized amalgam capsules. Th e use of amalgam capsules, the reduction in cavities due to improved dental hygiene, and the av ailability of other restorative materials have contributed to dentists reporti ng a downward trend in the us e of dental mercury amalgam. 2,3 This assumption may be overstated as some da ta suggests mercury use in dentistry has decreased only slightly. For example, amalgam manuf acturers and distributors are required to report every three years to th e Interstate Mercury Educa tion and Reduction Clearinghouse (IMERC) on mercury sales. In their 2004 submissi ons, data were presente d that indicated the sale of mercury in dental amalgam in the Un ited States in 2001 was 30.77 tons, decreasing only slightly to 30.39 tons in 2004. 4

1 The product sectors identified as equally meriting national attention were lamps, thermostats, dental amalgam, thermometers, and non-vehicle switches, relays and flame se nsors. Continued federal and state efforts in health care, schools, and end-of-life vehi cle switches was also encouraged.

2 Centers for Disease Control and Prevention. De ntal Amalgam Use and Benefits. Available at http://www.cdc.gov/ oralhealth/publications /factsheets/amalgam.htm

3 Berthold, M. Restoratives: Trend data shows shift in use of materials, American Dental Association News, 2002, 33(11), 10-11.

4 Interstate Mercury Education and Reduction Clearinghouse. Mercury-Added Products Database. Available at ( http://www.newmoa.org/prevention/mercury/imerc/Notification/index.cfm ) ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

23 DENTAL MERCURY AMALGAM WASTE MANAGEMENT Environmental Releases of Mercury

Mercury from dental amalgam is released to the environment through three primary pathways: in wastewater, as solid waste, and through crema tion of bodies containing dental amalgam. The majority of dental mercury amalgam is discharged from dental offices to wastewater treatment systems where it usually settles out in sewage sl udge that is either in cinerated, heat treated, landfilled, and/or land applied as biosolids (als o known as “sludge”). As there have been substantial accomplishments in reducing mercury in other business product sectors, dentists have become the largest source of mercury in wastewater influent. 5 A study funded by the American Dental Association (ADA) estimated that dental offices discharg e approximately six and a half tons of mercury per year to sewage treatment systems in the United States, which represents 50- 53 percent of influent loading. 6 While wastewater treatment pl ants can remove as much as 95 percent of the mercury from wastewater infl uent; the removed mercury is transferred from
wastewater to biosolids or ash from which it can enter the environment, or be released directly to the atmosphere. Dental offices discharging wa stewater to septic syst ems also have the potential to contaminate surrounding soils and groundwater, including wells. 7 Additionally, mercury and mercury amalgam particles can accumulate in the plumbing of dental offices and sewer lines, and over time, continue rel easing mercury into the wastewater.

In addition to wastewater concerns, waste amal gam that is improperly disposed in regulated medical waste (“red bag”) containers can be e ither incinerated or autoclaved, thus making it possible for volatilized mercury to escape into the environment. Mercury amalgam also accumulates on consumable dental supplies, such as cotton swabs and gauze. These materials are typically not considered potential ly infectious regulated medical wastes, and are disposed with the regular solid waste. In some areas, solid wa ste is incinerated so the mercury in this waste
can be released via air emissions.

Dental amalgam also contributes to mercury em issions from crematoria . A mercury flow worksheet developed for EPA Region 5 estimated that in the United States in 2005, just under 3,000 kilograms (6,613 lbs.) of mercury were releas ed to the environment from crematoria. 8,9

5 A study by the Association of Metropolitan Sewerage Ag encies (now the National Association of Clean Water Agencies) found that dental offices are the largest sour ce of mercury to publicly-owned treatment works (POTWs), contributing more than 35 percent of the influent merc ury for the POTWs studied. Association of Metropolitan Sewerage Agencies. Mercury Source Control & Pollution Prevention Program Evaluation: Final Report. March 2002 (Amended July 2002).

6 Vandeven , J. and McGinnis S.L. An Assessment of Mercury in the Form of Amalgam in Dental Wastewater in
the United States. Water, Air and Soil Pollution , 2005, 164, 349-366.

7 See Interagency Resource for Achieving Cooperation. Non-Residential Septic Tank Systems: Information for Business Users and Property Owners. Available at http://www.lhwmp.org/IRAC/publications/Septic%20Tank% 20Guidlines2004.pdf . Washington State requires that dentists disc harging to septic system s install a separator and obtain an industrial wastewater permit. See Washin gton Administrative Code: Chapter 173-216 WAC (nondomestic waste water); Chapter 246-290 WAC, state drinking water standards; and, Chapter 173-340 WAC, Model Toxics Control Act cleanup standards. Available at ( http://apps.leg.wa.gov/WAC/default.aspx ).

8 Cain, A. Mercury Flow Workbook, US EPA, Region 5, Excel Spreadsheet, January 2006.

9 Cremation is not the focus of this white paper but it is us eful to be aware of and prepared for the topic of cremation to be raised during public policy discussions on amalgam. ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS4 DENTAL MERCURY AMALGAM WASTE MANAGEMENT Alternatives to Dental Mercury Amalgam

If dental practices or patien ts do not want to use mercury amalgam, there are several nonmercury restorative materials available. Presently , there are six types of restorative materials: mercury amalgam, resin composite, glass ionom er, resin ionomer, porcelain, and gold alloys. 10 Each type of restorative material has advantag es and disadvantages. So me factors that influence which restorative material is used include: cost, strength, durability, location of cavity, and
aesthetics.

Historically, dental amalgam has been less expensive to the patient than other restorative materials and therefore has been favored for use. T oday, although the cost of alternative materials is often higher than amalgam, their use is increasing as patients prefer toot h-colored restorations
or have concerns over the use of mercury in their mouths (teeth ). With the increasing use of alternative filling materials, insurance providers ma y also reimburse or cover the cost for them.

Amalgam Separators and Dental A malgam Best Management Practices

For many municipalities, mercury discharges into sanitary sewer systems from dental offices do
not meet local sewer use ordinance limits for me rcury. To address this, dental offices can employ a number of best management practices (BMP s) to reduce mercury in their effluent. However, aside from using mercury-free alternat ives, proper installati on, operation, and maintenance of amalgam separators that meet or ex ceed the International Or ganization for Standardization (ISO) 11143:1999 (ISO 11143) standard along with proper maintenance of plumbing systems is the most effective means to signifi cantly reduce mercury amalgam discharges from
dental offices. 11 Appendix A lists resources available on- line that provide information on dental amalgam and best management practices.

Amalgam separators are increasing ly important to waste amalgam capture as more dental office systems are installing “dry” vacuum systems. These systems have only one filter while moretraditional “wet” vacuum systems have two filters. This means that without an amalgam separator, the dry vacuum systems have no secondary filtration.

Currently, nearly two dozen brands of amalgam se parators are available that meet the ISO standard of removing at least 95 pe rcent of the mercury amalgam. 12 Additionally, amalgam separators, which are readily available through dental supply companies, are in most cases straightforward to install, usually operate without electric ity or chemical addition, allow easy recycling of the collected amalgam contents, and are relatively low cost fo r both installation and maintenance. As a result of these factors and their effectiveness in reducing mercury in dental office effluent, requiring installation of amalgam separators has been a policy initiative in many states and municipalities.

10 From ADA. Dental Fillings Facts. Available at http://www.ada.org/prof/resources/topics/materials/ dental_fillings_facts_full.pdf . Accessed January 21, 2008.

11 More may about ISO standards at: http://www.iso.org/iso/standards_development.htm

12 Batchu, H. et al. Evaluating amalgam separators using an International Standard. Journal of the
American Medical Association , 2006, 137: 999–1005; and Fan, P.L. et al. Laboratory evaluation of amalgam separators. Journal of the American Medical Association , 2002, 133: 577– 584. ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS5 DENTAL MERCURY AMALGAM WASTE MANAGEMENT In addition to state and muni cipal requirements, in October 2007, the ADA amended its “Best Management Practices for Amalgam Waste” by adding a recommendation that dentists use amalgam separators. 13 The ADA defines dental BMPs as the use, proper waste handling, anddisposal in the operation of equipment that includes chairside traps, vacuum filters, and amalgam separators compliant with ISO 11143. As summarized below in Table 1, the ADA BMPs also include equipment maintenance, recycling, a nd using a commercial waste disposal service.

Table 1: ADA Best Management Practices for Amalgam Waste 13



## Dental Amalgam Separator Programs

According to information compiled by the QSC, th ere are eleven states and numerous municipalities with mandatory programs requiring the use of dental me rcury amalgam separators. Information for this report was solicited from Metropolitan C ouncil Environmental Services (Minneapolis/St. Paul Minnesota publicly-owned treatment works), Maine, Massachusetts, New York, and Washington. Information on the King County, Washington, program was

13 ADA. Best Management Practices for Amalgam Waste. 2007. Available at http://www.ada.org/prof/resources/ topics/topics_amalgamwaste.pdf . Accessed January 19, 2008. ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

DO DON’T

Do use precapsulated alloys and stock a variety of capsule sizes Don’t use bulk mercury

Do recycle used disposable amalgam capsules Don’t put used disposable amalgam capsules in biohazard containers, infectious waste containers (red bags) or regular garbage

Do salvage, store and recycle non-contact amalgam (scrap amalgam) Don’t put non-contact amalgam waste in biohazard containers, infectious w aste containers (red bags) or regular garbage

Do salvage (contact) amalgam pieces from restorations after removal and recycle the amalgam waste Don’t put contact amalgam waste in biohazard containers, infectious w aste containers (red bags) or regular garbage

Do use chair-side traps, vacuum pump filters and amalgam separators to retain amalgam and recycle
their contents. Don’t rinse devices containing amalgam over
drains or sinks

Do recycle teeth that contain amalgam restorations. ( Note: Ask your recycler whether or not extractedteeth with amalgam restorations require disinfection.) Don’t dispose of extracted teeth that contain amalgam restorations in biohazard containers, infectious waste containers (red bags), sharps containers or regular garbage

Do manage amalgam waste through recycling as much as possible Don’t flush amalgam waste down the drain or toilet

Do use line cleaners that minimize dissolution of amalgam Don’t use bleach or chlorine-containing cleaners to
flush wastewater lines6 DENTAL MERCURY AMALGAM WASTE MANAGEMENT ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

provided by the Washington Department of Ecolo gy. The QSC selected these six programs because they represent a variety of types of progr ams and occur in diverse geographic areas. They include states with large populations and urban areas, such as New Yo rk, and states that are largely rural, such as Maine.

While not all programs had hard data on their re sults, data from Massachusetts, King County, and the Metropolitan Council Environm ental Services (MCES) clearly demonstrate the value of amalgam separator installation programs. The Massa chusetts and King County programs have each realized approximately 50 percent reductions of mercury in biosolids. The MCES program has tracked their progress by monitoring mercury in wa stewater influent, and has achieved a 50 percent reduction in the amount of mercury disc harged to the treatment plant.

Below is a discussion of some program component s that are common to the programs reviewed and a list of some lessons learned by these and other programs. (Note: full descriptions of these programs are available in a separate document titled, “Case Studies of Five Dental Mercury Amalgam Separator Programs”.)

Common Program Components

Precursors to State Programs The programs reviewed indicate that local and re gional dental amalgam efforts often seem to be useful precursors to the developm ent of statewide dental amalgam programs. Local (in-state) programs often garner invaluable knowledge and experi ence that eventually he lps shape their respective state’s dental mercury reduction initiatives. Two such local programs reviewed for this paper are King County, Washington’s pilot effort, and Metropolitan Council Environmental Services’ (MCES) program.

Similarly, regional multi-state efforts have played a role in developing some state programs. For instance, dental sector mercury reduction goals were set in 2005 under the Mercury Action Plan of the New England Governors and Eastern Canadian Premiers such that by 2007 seventy-five percent and by 2010 ninety-five percen t of the region’s dentists who ge nerate mercury amalgam wastewater would install amalgam separators. These regional mercury reduction goals served as motivators for the development of the Maine a nd Massachusetts programs.

Currently, the Great Lakes States are developi ng a regional Great Lake s Mercury in Products Phase-Down Strategy for mercury co ntaining products. In that stra tegy, dental mercury amalgam is one of the primary products being addressed. This strategy most lik ely will result in more Great Lakes states developing dental amalgam BMP programs, which are expected to include requiring dental mercury amalgam separators.

Voluntary vs. Mandatory ProgramsAll of the programs examined initially began as voluntary initiatives with Memoranda of Understanding (MOUs) with state dental as sociations, or as a result of regional initiatives that included recommendations for the development of mandatory programs. Regardless of how they began, all the programs reviewed for this paper now have mandatory components. For example, the7 DENTAL MERCURY AMALGAM WASTE MANAGEMENT ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

Washington State Department of Ecology initially negotiated an MOU with the Washington State Dental Association to give dentists a two-year grace period to install amalgam separators and implement other best management practices. Unde r the voluntary program, only 40 percent of dentists in Washington installed separators. This pr ompted the Department of Ecology not to extend the MOU and to require separato r installation under ex isting state hazardou s waste regulations. 14 Similarly, in Massachusetts, a lthough an MOU between Massachus etts Department of Environmental Protection and the Massachus etts Dental Society helped to raise awareness about amalgam separators, their use by dentists only increased modestly until a two-pha se mandatory program evolved with incentives for early adopters. MCES saw comparable low separator installation ratesuntil dentists were told they would be required to obtain a discharge permit, pay permit fees, conduct sampling, and submit reports to MCES if they di d not install a separator. After dentists were told that, separator inst allation rates in the MCES jurisdiction increased to 100 percent. Table 2 identifies the components of programs reviewed in this paper.

Table 2: Mandatory vs. Voluntary Components of Programs Reviewed

While the addition of amalgam separators to the ADA’s BMPs should increase their installation, these are voluntary industry-recommended standards, and therefore may not result in a sufficient number of dentists adopting them to meet impor tant environmental standards. When considering whether separator installation should be volunt ary or mandatory, program managers should consider information published in the Fall 2007 edition of the ADA Professional Product Review 15 where it was reported that a “surve y of [ADA Clinical Evaluator Pa nel] members shows that relatively few panel members own an amalgam separator or plan to purchase one”. 16 Also, while participation rates will be higher with mandatory prog rams, starting an amalgam separator installation program under a voluntary initiative should not be overlooked because it can serve as a meaningful first step in creating a program.

14 Washington State Dangerous Waste Regulations, Washington Administrative Code, 173-303

. http:// www.ecy.wa.gov/programs/hwtr/reg_comp_guide/173-303.HTM

. 15 Dental Separators: A peer review. ADA Professional Product Review , 2007, 4:1.

16 The ADA Clinical Evaluator Panel is a volunteer group of ADA members who contribute feedback for the clinical input segments of the ADA Professional Product Review TM program. More on the ADA Clinical Evaluator Panel can
be found at http://www.ada.org/prof/re sources/pubs/ppr/ace.asp Component Program

Voluntary separator insta llation, but later a discharge permit was required if separators were not installed. Permitting would have included paying fees, meeting a mercury limit, and samp ling and analyzing wastewater. MCES

Voluntary separator installati on followed up with mandatory component. Massachusetts, Washington State, King County

Mandatory separator installation but special considerations if separators were installed prior to the requirements going into effect. Maine, New York8 DENTAL MERCURY AMALGAM WASTE MANAGEMENT ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

Separators All of the programs examined require installation of amalgam separators compliant with at least the ISO 11143 Standard; however, specific removal e fficiency requirements vary among programs. MCES and New York require installa tion of separators with a removal efficiency of 99 percent. By contrast, Massachusetts and Maine allowed a mini mum removal efficiency of 95 percent, if the separators were installed prior to their laws going into effect. Separators installed after the laws
took effect must have a minimum remova l efficiency rating of 98 percent.

The method for ensuring that accep table separators are installed varies among the programs. In some programs, the regulating body provides a list ofapproved separators. In other programs, dentists are provided a list of approved separators but may purchase separators not on the approved list as long as they provide document ation that the separato r’s removal efficiency meets regulatory requirements. Programs that require separators to be “certified” should clearly define what constitutes certification and designate acceptable “certification body/ie s”. The case study programs all recommend against evaluating and testing separato rs by individual states or POTWs. This has proven to be a difficult, time-consuming task, and once a regulator evaluates and approves certain separator models, they become th e default certification body from th at point forward. This function can be more efficiently accomplished by establis hed certification bodies wi th significant experience
in ISO 11143 work. Table 3 below identifies amal gam separator requirements of the programs examined.

Table 3: Separator Requirem ents of Programs Reviewed

17 Note that some older separator models on MCES’ list of approved separators may not be certified. Separator Requirements Program

Pass the ISO 11143 Standard King County, Maine, Massachusetts, MCES, New York, Washington

99 percent removal efficiency according to ISO 11143 Standard MCES, New York

98 percent removal efficiency acco rding to ISO 11143 Standard and 95 percent if installed prior to law going into effect Maine,
Massachusetts

95 percent removal efficiency (The basic ISO 11143 Standard) King County, Washington

Specific list of separators provided by regulator King County, Maine, MCES

Certified. Certification is a quality control, conformity assessment process in addition to ISO 11143 testing. MCES 17

, New York

Alternative separator models can be approved if the dentist takes onthe burden of ensuring that the unit meets all Maine DEP specifications including documentation tha t: (1) the separator achieves 98 percent efficiency at maximum flow, and (2) Maine DEP waste bureau has determined that the unit is "totally enclosed". Maine9 DENTAL MERCURY AMALGAM WASTE MANAGEMENT ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

Best Management Practices Beyond separator installation, all the programs review ed require dental practices to use BMPs in
order to control releases of me rcury. Although, specific BMPs vary from program to program, they include practices such as:

• recycling of all mercury-containing waste;

• requiring all mercury- containing wastewater to pass through an amalgam separator;

• storage/recycling requirements fo r waste amalgam capsules; and

• training dental office staff on the proper procedur es for operating and maintaining an amalgam separator.

Exemptions When setting up an amalgam separator program, it is important for program managers to decide whether and what types of dental practices may receive an exemption. The programs reviewed for this paper varied in how they addressed exemptions for specialty dentists such as orthodontists, periodontists, prosthodontists, and oral/maxillofacial surgeons. Specialty dentists are not commonly thought to place or remove mercury amalgam restora tions so some have been exempted from some of the programs. Programs have tended not to ex empt endodontists as they can remove a significant amount of amalgam. Variations between stat e programs are apparent wh en the exemptions in Maine and Washington are compared. Maine law exempts only oral and maxillofacial surgery practices. In contrast, Washingt on State did not set its exemption based on type of practice rather they exempt specialists only if they:

• Do not place or remove amalgam fillings on ten or more practice days during the year and, if inspected, are able to show co mpliance with this requirement.

• Dispose of all other dangerous wastes, such as l ead foils or used fixer, in an appropriate manner. No dangerous wastes shoul d be intentionally put down the drain, disposed of as part of medical (red bag) waste, or sent to landfill with out explicit permission from local authorities. 18

Lessons Learned

In addition to the common program components that were identified through the six case studies, lessons learned by the programs profiled in the case studies and by other programs can be useful. Below is a set of lessons learned that provide valuab le information for other states as they consider
and create dental am algam programs.

Amalgam Separator Selection

• To avoid problems associated with regulators havi ng to review reports and certificates from unknown sources, states requiring th e use of ISO 11143 compliant amalgam separators should determine and publicize who may test and certify the units.

• Programs should not adopt a list of approved sepa rator models from another regulatory agency without first evaluating that agency’s program.

• States should be aware that removal efficiency test results for separators can currently be manipulated by manufacturers using any maximum fl ow rate they want during ISO testing.

18 Washington State Department of Ecology. Designation guidance for specialty dentists. Available at http:// www.ecy.wa.gov/dentalbmps/specialty_guidance.html . Accessed January 21, 2008.DENTAL MERCURY AMALGAM WASTE MANAGEMENT The ISO is considering this issue in a revi sion to ISO Standard 11143. More information on this revision is available in Appendix B.

Amalgam Separator Oper ation and Maintenance

• When setting guidelines and regulations for operation and maintenance of separators, states should be aware that many models of separators have a mechanism that allows wastewater to bypass the separator with little or no treatment if there is excessive flow or when the filters are full or clogged. As a re sult, separators should not be operated at flow rates in excess of the ISO tested flow rate, unless the se parator has a built in flow restrictor and an adequately-sized surge tank.

• Since timely and appropriate maintenance of se parator systems is crit ical, states should ensure that dental BMPs always include the “do’s and don’ts” for properly cleaning amalgam separators, traps, filters, and other related plumbing in dental practices. Bleach and other improper cleaning materials may cause mercury ‘s pikes’ into wastewat er originating from
dental facilities and eliminate the mercur y reductions derived from separators.

• Dental practices and their vendors should be re quired to follow manufact urer’s directions on separator installation, operation and maintenance, and maintain records of these activities.

Communication and Implementation

• When developing a dental amalgam reduction program, communicating with staff operating programs already in existence is highly advisabl e. More than likely these programs have already addressed the key issu es that could arise.

• As states create and implement amalgam separa tor programs, they should plan to work with a wide variety of stakeholders from envi ronmental groups and pub licly-owned treatment works to the ADA and dental office supply compan ies. A list of potential stakeholders and their roles are available in Appendix C.

• States should be aware that a mercury waste manifest tracking system can help ensure proper recycling of mercury-containing wastes.

• To understand where coordination may be bene ficial, programs should identify which entities in addition to environmental agencies visit dental facilities regularly. For example, licensed plumbing inspectors are in a position to observe and report on amalgam separator
installation or lack thereof. The Connecticut Department of Envir onmental Protection has signed an MOU with x-ray equipment inspectors for them to include inspection of amalgam separators in their periodic visits to dental offices.

• Resources will always be an issue. States should be aware that some programs found that significantly more resources and staff time were needed to implement the program than was originally anticipated. Also, without funding to maintain tec hnical assistance visits and to pursue regulatory violations, pr ograms may struggle to succeed.

• Regulators need to be prepared to offer gui dance on all aspects of their dental mercury amalgam reduction programs including:

ο Providing information as to which amalga m separator models are acceptable since failure to provide this information may be interpreted as blanket approval of any amalgam separator; and

ο Identifying testing laboratories and certification bodies from which amalgam separator manufacturers may contract for services. ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

1011 DENTAL MERCURY AMALGAM WASTE MANAGEMENT • Developing a good working relationshi p with the state dental asso ciation is vital to program success as they can help with outreach and education.

• State environmental agencies should enlist dent al licensing agencies and boards in outreach
efforts.



## Recommendations for Future Action

Although a lot of information has been gathered and much has been learned from programs that are addressing dental mercury amalgam, there are st ill outstanding issues that need to be studied
and resolved. Below is a list of recommended actions to begin to address some of these issues.

• States should encourage EPA to designate a national or internationa l organization to conduct separator testing under ISO 11143. Data fromthe testing results could be used to develop one list of separators th at achieve 95% reduction or bette r at certain established flow rates. States and municipalities could use thes e data as the benchmark for an approved list of separators. If that is not possible, a st akeholder group should be established to recommend answers to questions such as:

ο Who is qualified to perform IS O 11143 testing and certification?

ο By whom and how are the laboratories a nd certification bodies to be accredited?

ο Has the ISO test been performed correctly?

ο Does each regulator in each jurisdiction ha ve to evaluate test reports and certificates?

• Education of dental office staff regarding amal gam separators and BMPs should be pursued. Some specific recommendations fo r this include the following:

ο Dental assistant schools, de ntal hygiene schools, and de ntal schools should be required to teach students proper storage, us e, handling, and spill clean-up of mercury amalgam. This will ensure that all positions in a dental practice that may handle mercury amalgam receive appropriate training.

ο Amalgam BMPs should be included in th e continuing education programs for dentists, dental assistants, and hygienists.

ο When state and local programs have statutes in place that uniquely apply to dental practices, compliance with these requirements should be reviewed in the applicable state’s dental licensure process.

• Mercury and mercury amalgam particles can sett le at low points in plumbing and remain in the pipes of a facility or downs tream sewer lines for many years. As a result, releases can
occur over time as work is done on dental office plumbing systems, and during system cleaning and disinfection procedures. Therefore, dental office staff and plumbers need to be made aware of this issue and taught proper procedures for addressing it.

• Eliminating or decreasing mercury emissions to air during cremation is an emerging area of

concern.

• Studies should be pursued to gather more in formation on mercury air emissions in dental offices during routine dental procedures, sepa rator operation a nd maintenance, and handling of waste amalgam.

• There are very limited data on the mass load of mercury in municipal wastewater treatment plants, particularly carefully controlled studi es before and after the implementation of ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUSDENTAL MERCURY AMALGAM WASTE MANAGEMENT amalgam BMPs and installation of amalgam separa tors in tributary dent al offices. Since dental amalgam represents 50% of the mercury influent to municipal treatment plants and the precise partitioning of that mercury to treatment plant grit, biosolids, air emissions, and effluent may be important to mercury contro l policy decisions, such studies should be conducted as soon as possible. The studies shoul d be national in scope and funding with participating municipalities representing the range of wastewater treatment plant size and technology in the United States.



## Wrap-up

State and federal mercury reduction programs in creasingly focus on eliminating human uses and releases of mercury. Given that dental practices contribute significant amounts of mercury to the environment, addressing management of de ntal mercury amalgam is important. This paper provides information on features of and lesso ns learned from some cu rrent amalgam separator programs. Providing this information lays the groundwork for more discussion of amalgam separator programs and generally addressing mercury releases from dental practices. ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

1213 DENTAL MERCURY AMALGAM WASTE MANAGEMENT 

## Appendix A Some Online Dental Amalga m Information Resources
January 2008

General

Northeast Waste Management Officials’ A ssociation’s Mercury-Dental Topic Hub - http://www.newmoa.org/prevention/topic hub/bibliography.cfm?hub=103&subsec=7&nav=100

The National Association of Clean Wate r Agencies’ Mercury Initiatives - http://www.nacwa.org/index.php?option=com_ content&task=view&id=64&Itemid=143

Best Management Practices

Best Management Practices for Dental Offices in New Hampshire: Tips for Reducing Hazardous, Universal, and Solid Wastes - http://www.des.state.nh.us/nhppp/dentalBMP.pdf

City of Boulder Best Management Practices for Dental Waste

- http://www.p2pays.org/ref/03/02192.pdf

Connecticut’s Best Management Practices for Mercury Amalgam - http://www.ct.gov/dep/cwp/view.a sp?a=2708&q=323996&depNav_GID=1638

The Environmentally Responsible Dental Office: The Oregon Dentists’ Guide to Best Management Practices of Dental Waste - http://www.p2pays.org/ref/04/03294.pdf

Narragansett Bay Commission’s En vironmental Best Practices fo r the Management of Waste Dental Amalgam – http://www.narrabay.com/Documents/PDFs/NewDentalBMP.pdf

Recycling Amalgam Waste and Other Best Mana gement Practices for Your Dental Office - http://www.newmoa.org/prevention/t opichub/103/Chicago_Dental_Society.pdf

Vermont’s Environmental Best Management Pr actices Guidelines for Dental Offices – http://www.mercvt.org/pdf/dentalbmp.pdf

Washington State’s Best Ma nagement Practices for Dental Office Wastes - http://www.ecy.wa.gov/dentalbmps/

Dental Office Pollution Prev ention and Waste Management

Controlling Mercury in Wastewater Di scharges from Dental Clinics - http://www.nacwa.org/images/s tories/public/2006-01dmercwp.pdf ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUSThe Environmental Guide for Dentistry: How to Properly Manage Waste from your Dental
Practice - http://www.neiwpcc.org/neiwpcc_docs/maine_dental.pdf

The Environmentally Responsible Dental Office: A Guide to Proper Waste Management in
Connecticut Dental Offices – http://www.ct.gov/dep/lib/dep/mercury/gen_info/NWF-CTdentalreport.pdf

Indiana’s How to Prevent Pollution From Your Dental Practice: A Guide for Dentists - http://www.p2pays.org/ref/03/02140.pdf

Massachusetts’ Dental Amalgam & Mercury Recycling webpage - http://www.mass.gov/dep/service/dentists.htm#intro

New York’s Guide for Dentists for Ma naging Mercury and Amalgam Wastes - http://www.dec.ny.gov/chemical/8845.html

Other

Fillings: You Have Choices, Mercury Am algam, & Other Filling Materials - http://www.ct.gov/dep/lib/dep/mercu ry/gen_info/fillings_brochure.pdf

Recognition for Dental Providers Us ing Amalgam Removal Equipment - http://www.pca.state.mn.us/publications/wq-wwtp1-02.pdf

Wisconsin’s Municipal Mercury Po llutant Minimization Program - http://dnr.wi.gov/org/cae r/cea/mercury/potw.htm ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

DENTAL MERCURY AMALGAM WASTE MANAGEMENT 14

## Appendix B
ISO 11143 Standard and Its Revision

Information on the current ISO 11143 standard, se t in 1999 and currently being revised, can be found on the ISO’s website at http:// www.iso.org . The ISO 11143 standard spells out how an amalgam separator is to be tested in a laboratory, bench-top setting.

The main expected change in the testing standard as a result of the revision is the setting of a
threshold for the “maximum flow rate”. The thres hold rate would be 1 lite r/minute. In the past, some separators were tested at lower rates whic h meant that a manufacturer could petition to be on a state or local government’s list of approved m odels by simply testing at a lower flow rate to achieve a higher removal efficiency. Another li kely revision to the st andard is a modification to standardize the flushing period duration. Also, the revised standard is expected to require additional information in the laboratory test repo rt. This will give more technical information about the separator, such as physical dimensi ons, a photograph of the separator, more removal efficiency data (rather than just summary data ), and the volume of the waste solids carrying capacity. ... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

DENTAL MERCURY AMALGAM WASTE MANAGEMENT 15... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

DENTAL MERCURY AMALGAM WASTE MANAGEMENT 16 

## Appendix C Dental Amalgam Stakeholders

Amalgam Separator Manufact urers and Distributors market amalgam separator equipment that meet the ISO 11143 standard. They sell equipmen t primarily through dental supply companies, and occasionally directly to dental offices. Most , but not all, also offe r recycling and replacement services for full separator canisters.

American Dental Association (ADA) represents the aggregate inte rests of State Dental Associations and individual member dentists throughout the United States on many issues, including waste management issues. ADA conducts resear ch on waste management issues too complex
for individual State Dental A ssociations and performs educa tional and lobbying functions similar to State Dental Asso ciations on a national level. Not all dentists belong to the ADA.

Dental Assistant Schools, Dental H ygienist Schools, and Dental Schools train future dental assistants, dental hygienists, and dentists. Working with them to deliver curriculum on separator installation, operation and maintenance, and BMPs can help institutionalize their use.

Dental Office Supply Companies sell traps, filters, and amalgam separators to individual dental offices. They identify available models and sizes of separators for an individual dental office. Many companies will also install separators as we ll as periodically inspect them for needed canister replacement. They gene rally do not transport or “t ake away” the used canisters.

Dental Patients are a driving force in the switch to non- amalgam restorations as the effects of mercury on health and the environmen t are becoming more widely known.

Dental Practices including staff use dental amalgam, generate waste amalgam, and implement waste amalgam capture and recycling practices. So me are required to report waste management practices to regulatory agencies.

Environmental Groups , such as Environmental Defense, the Mercury Policy Project, and the National Wildlife Federation, advocate for reductions in the use of mercury in products and for proper management and control of mercury wastes.

Insurance Companies and Other Entities that Reim burse or Cover the Cost of Dental Services provide reimbursement and cost coverage for dent al services. These may be private dental insurance companies as well as public programs such as Medicare and state programs. Whether certain dental services are covered, such as non-amalgam restorations, can affect dental patients’ choices.

Mercury Waste Handlers and Recyclers manage, ship, and/or pr ocess the mercury amalgam waste captured in traps, filters, and separators. Mercury waste that is not recycled via the amalgam separator manufacturer is recycled or dis posed of via independent waste handlers or mercury retort facilities. All major mercury reto rt companies have developed waste amalgam shipping packages tailored for use by dental offices.... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

... QUICKSILVER CAUCUS

DENTAL MERCURY AMALGAM WASTE MANAGEMENT 17 Municipal Government – Departments of Public Works – Publicly Owned Treatment Works (POTWs) receive almost all of the waste dental mercury amalgam not captured and recycled by the dental office. The municipalities evaluate mercury impact on collection systems, treatment plant effluent, and biosolids. POTWs may admini ster pretreatment programs or pollutant minimization programs, and local sewer ordinances. Th e local ordinances may require dental office implementation of amalgam BMPs, or other optio ns to reduce mercury, including installation of amalgam separators.

State Dental Associations or Societies represent the aggregate inte rests of individual member
dentists within the state on many issues, including dental waste management. They conduct educational outreach to their members, lobby st ate government on their members’ behalf, and report to the ADA. Opinions of individual state associations can differ from those expressed by the ADA. Not all dentists belong to th eir state association or society.

State Environmental Agencies evaluate and regulate mercur y releases to the environment through the establishment of envi ronmental standards for the pr otection of human health and the environment. They may implement volunta ry or mandatory programs for dental office amalgam capture and recycling. Some state ag encies may also impose conditions or requirements on POTWs for the handling of their biosolid s, such as land application, incineration, or other management methods. State agencies regulate municipal so lid and other waste facilities, such as municipal solid waste incinerators and landfills, and land application of sewage biosolids and biosolids incinerators.

U.S. Environmental Protection Agency (EPA) evaluates and controls mercury releases to the environment on a national level. Agency sta ff may encourage voluntary mercury source reduction or require mercury source reduction for merc ury point sources includ ing dental offices. The EPA also develops standards for waste mana gement and air quality. The EPA implements reduction initiatives primarily by partnering with state agencies, by providing technical assistance and research support a nd in some cases by providing fu nding, such as pollution prevention grants.

### ECOS 08.002