Waste disposal in dental practices f1 / dental implant courses by Indian dental academy

WASTE DISPOSAL
in
Dental Practices

INDIAN DENTAL ACADEMY
LEADER IN CONTINUING Education
www.indiandentalacademy.com

Introduction.
Environmental hazards caused by materials used in dentistry.
Regulations affecting dental practice.
Planning.
Designation.
Categorisation.
Segregation.
Handling and storage.
On-site treatment.
Treatment off-site.
Contingency planning
Public relations.
Summary and Conclusion.
References.
CONTENTS

Introduction
Modern dentistry has been described as probably among the
least hazardous of all occupations, although there remain
many hazards in dental practice, like exposure to infectious
diseases, radiation and mercury. Where the hazards cannot
be excluded from the work place, good occupational hygiene
practices need to be adopted by dental practitioners.
However, there is probably less awareness of the
environmental impact we dentists have as individuals in our
professional lives and of the remedial measures we should be
taking.

Environmental hazards caused by materials
used in dentistry
 Chemicals used like etchants and monomers, X-ray
processing solutions, drugs etc cause inactivation of the biological
systems.
 Contaminated needles and scalpel blades have been
sources of infection and allergies.
 Base metal debris and mercury from amalgam cause
poisoning of the biological systems.
 Liquid waste containing toxic substances flushed down a
drain or sink to sewers, might affect the biological waste treatment
works in the sewers.

Health hazards
Blood, body fluids and body secretions which are constituents of
bio-medical waste harbour most of the viruses, bacteria and parasites
that cause infection. This passes via a number of human contacts, all
of whom are potential ‘recipients’ of the infection. HIV,Hepatitis,
tuberculosis, pneumonia, diarrhoeal diseases, tetanus, whooping
cough etc., are other common diseases spread due to improper waste
management.

Improper practices such as dumping of bio-
medical waste in municipal dustbins, open spaces,
water bodies etc., leads to the spread of diseases.
Emissions from incinerators and open burning
also leads to exposure to harmful gases which can
cause cancer and respiratory diseases.
Exposure to radioactive waste can in the waste
stream can also cause serious health hazards.
Bio-medical waste can cause health hazards to
animals and birds.

Hence as a measure for the safe disposal of dental
waste, different organizations around the globe have
developed regulations to safeguard the natural
environment.

REGULATIONSREGULATIONS
AFFECTINGAFFECTING
DENTALDENTAL
PRACTICEPRACTICE

Dental offices are subject to a variety of national, state, and
local regulations concerning the safe handling of their waste
materials. The US Congress set up few agencies for this
purpose, for e.g.,
Environmental Protection Agency (EPA)
Occupational Safety & Health Administration (OSHA)
Centers for Disease Control and Prevention (CDC).

The EPA's mission is to protect human health and to
safeguard the natural environment (air, water, and land.)
OSHA’s mission is to prevent work-related injuries,
illnesses, and deaths. OSHA promulgates regulations, also
known as “standards,” which have the power of law. OSHA
then applies the tenets of its standards through inspections
and when necessary the imposition of citations and
penalties.

The CDC’s mission is to promote health and quality of life by
preventing and controlling disease, injury, and disability.
The CDC is interested in the well being of healthcare
workers, their patients, and the community. Advice to
healthcare providers usually comes in the form of
recommendations. CDC recommendations, however, are
usually so well developed they commonly serve as industry
“gold” standards.
To be in compliance, dental offices must first be aware of all
mandates - national, state and local rules - concerning
regulated waste applicable in their area.

In exercise of the powers conferred by section 6, 8 and 25 of
the Environment (protection) act, 1986 the central government,om
2nd
June notified the rules for the management and handling of bio-
medical waste. These rules are called the Bio-Medical Waste
(Management and Handling) (Second Amendment) Rules, 2000.
These rules apply to all persons who generate, collect, receive,
store, transport, treat, dispose, or handle bio medical waste in any
form.
According to this,"Bio-medical waste" means any waste, which is
generated during the
diagnosis, treatment or immunisation of human beings or animals
or in research activities pertaining thereto or in the production or
testing of biologicals.
The Bio-medical Waste (Management and Handling) (Second Amendment)
Rules,2000.

PLANNING
A regulated waste management plan contains a number of
important components. These include
1. Designation
2. Categorization
3. Segregation
4. Handling And Storage
5. On-Site Treatment
6. Treatment Off-Site
7. Contingency Planning
8. Public Relations.

DESIGNATION
Many people mistakenly consider the terms hospital
waste, biohazardous waste, biomedical waste, red bag waste,
medical waste, and infectious waste to be synonymous.
However, hospital waste, dental office waste, or household
waste refers to the total discarded solid waste (which includes
solids, liquids, semi-liquids, and gases) generated by all
sources within a given location.

Various Types of Waste
Contaminated
Waste
Items that have had contact with blood or other body fluids and
secretions, such as saliva.
Infectious
Waste
Waste capable (as shown through epidemiological studies) of causing an
infectious disease - sufficiently contaminated with blood or other body
fluids so as to be able to transmit disease.
Medical /
Dental
Waste
Any solid waste that is generated in the diagnosis, treatment, or
immunization of human beings or animals in research pertaining thereto,
or the production or testing of biological agents. The term does not
include hazardous waste (e.g., harsh or reactive chemicals) or household
waste.
Regulated
Waste
Infectious medical/dental waste that requires special storage, handling,
neutralization, and disposal.

Infectious waste is a small subset (estimated to be 3% in
hospitals and 1-2% in dental offices) of the total waste to be
discarded. Infectious waste is the part of medical/dental
waste that has been shown, through controlled studies, to be
capable of transmitting an infectious disease. For e.g.,
contaminated sharps, teeth, pathological waste and blood
soaked items. Also known as hazardous waste.
Factors such as the number and virulence of the
microorganisms present, host resistance, and the presence
and availability of portals of entry play important roles in
whether an infection does or does not occur.

Regulated waste, according to OSHA definition, is liquid or
semi liquid blood or other potentially infectious materials and
items that would release blood or other potentially infectious
materials if compressed.
Other potentially infectious materials are body fluids that are
visibly contaminated by blood.
Infectious/hazardous waste is also included under
Regulated Waste because certain segregation, storage, and
disposal procedures must be followed.
While this waste is in the dental office and a potential hazard
to the employees, it is covered by OSHA regulations.

CATEGORIZATION
Many categories of infectious waste have been proposed.
The real qualification is if an item or material meets the
scientific definition of “shown capable of producing an
infectious disease.”
For dental offices, there are five types of regulated waste. All
five possess the capabilities of transmitting infectious
diseases and, therefore, require special handling, storage,
and disposal methods

The five types are:
1. Bulk (in a liquid or semi-liquid form) blood or blood
products and other potentially infectious materials, OPIM (for
dentistry, saliva is considered to be as hazardous as blood);
2. Items such as a cotton roll saturated with blood/saliva or
OPIM which readily release fluids during handling (by
squeezing or are actually dripping or caked);
3. Pathologic waste (e.g., exfoliated or extracted teeth);
4. Used sharps (contaminated items that can penetrate
intact skin), such as injection needles, scalpel blades,
instruments, burs, and broken contaminated glass;
5. Potential sharps, such as anesthetic carpules, which can
contain aspirated blood and could break possibly causing
injury and exposure.

SEGREGATION
•All waste from dental offices can be divided into two basic
categories: Regulated and Non-regulated.
•Regulated waste must be placed into appropriately designed
containers, usually red biohazard bags or sharps boxes.
•Ideally, segregation should occur as close as possible to the
point of origin.
•The person disposing of an item should know best which type
of container to select.
•Segregation increases patient and practitioner safety and
prevents contamination of non-regulated waste.

•The majority of soiled items are not regulated waste. For
example, used gloves, masks, and gowns are not considered
regulated dental waste and thus can be added to the regular
trash.
•The same is true for environmental barriers (e.g., plastic bags or
sheets and aluminum foil) used to cover equipment during
treatment.

HANDLING AND STORAGE
 Safe handling of regulated waste is essential. Written
procedures will help in this process. Involved personnel must
be informed of the possible health hazards present and trained
in appropriate handling, storage, and disposal methods.
 Stored regulated waste must be placed into labeled or
color-coded bags or containers. Usually such items are red and
have biohazard symbols attached.


The receptacles should be covered with properly fitted lid
that can be opened with a foot pedal. Keeping the lid closed
prevents air movement, as well as the spreading of
contaminants.
Waste receptacles should be lined with sturdy plastic bags
that can be removed without touching the interior of the
liner. Double-bagging of liners may also be recommended
to eliminate accidental exposure should one of the bags rip
or tear.
Ideally, regulated waste should be stored as soon as
possible with a minimum of transport.

Maintaining bag and container integrity is vital and overfilling
must be avoided.
Regulated waste must be stored in a properly ventilated,
secured area that cannot be readily seen by patients.
Generally, waste should not be stored for more than 30
days.
Waste containers must be designed to prevent the
development of offensive odors.
Waste is discarded in a leak - resistant package that is
impervious to moisture.
The bag is sealed to prevent leakage during transportation to
the final dumpsite.

If hazardous waste is shipped, store the containers in an
exclusive refrigerator to maintain the integrity of the contents
and to control odor until the pick-up date.
In almost all locations, blood in a liquid or semi-liquid form,
even when mixed with other fluids such as saliva, can be
poured or evacuated directly into the office waste water
system. Sink traps and evacuation lines should be thoroughly
rinsed at least daily. Passage of an effective, environmentally
compatible disinfectant or evacuation cleaner (low sudzing)
through the system would help. A final water rinse should
follow.

Non-Hazardous waste
Disposable paper towels, paper mixing pads, disposable
covers of operating surfaces.
Should be discarded in separate covered containers made
of durable material such as plastic or metal receptacles.
For ease in handling, the receptacles should be lined with
plastic bags.

OSHA HOUSEKEEPING REQUIREMENTS
The housekeeping section of the OSHA Bloodborne
Pathogens Standard includes provisions for handling :
Contaminated sharps
Spills
Broken contaminated glassware
Regulated waste.

Sharps.
The term sharp means any sharp or pointed object that
can penetrate the skin or oral mucosa. In dentistry, the
most common types of sharps are:
Needles
Scalpel blades and disposable scalpels
Exposed ends of dental arch wires
Broken glass
Burs and endodontic instruments


The OSHA Bloodborne Pathogens Standard contains specific
guidelines concerning sharps containers:
 Sharps containers must be closeable, leak-proof, puncture-
resistant items labeled with a biohazard symbol or color-coded
red to identify it as a hazard.
 They should be capable of maintaining their impermeability
during storage, transport, treatment, and disposal. This will
help prevent occupational exposure to container contents.
Sharps should be quickly placed into sharps containers after
use. They must be placed into acceptable containers as close
as practically possible to their point of use.

Sharp items should be considered as potentially infectious
materials and thus handled with extraordinary care to prevent
accidental injuries.
Contaminated sharps are never touched with bare hands,
but by wearing appropriate gloves or by using transfer
forceps.
Sharp containers should be replaced routinely before they
are over filled.

Discarding used needle.
Of special concern among contaminated sharps are used
needles. The CDC estimates that healthcare workers sustain
nearly 600,000 percutaneous injuries annually involving
contaminated sharps. In response to a continuing concern of
exposure and the development of technological advances that
increase employee protection, the US Congress passed the
Needlestick Safety and Prevention Act in 2000. Enforcement
of the new provisions in the standard began on July 17, 2001.

Proper handling of sharps is essential because personal
protective barriers, such as gloves, will not prevent all
needlestick accidents. To minimize the potential for
exposures, needles should not be recapped, bent, or broken
by hand.
Instead a “hands-free” or a “one-hand” technique must be
used.
The hands free technique involves the use of a cap
holder, which allows the slipping of the needle into it without
touching it.

In a one-hand technique, the needle guard is placed on a
tray, and the used needle is wiggled into the cover. Once
the end of the needle is covered, it maybe safely brought in
to position.

The recapped needle is then discarded in the nearest sharps
container.

Needle disposal unit.

Infectious material spills.
 Spilled or dropped potentially infectious materials such as
gauze saturated with blood, must be cleaned up immediately.
Utility gloves and protective barrier clothing are worn.
The area of spillage is wetted with a suitable disinfectant
such as 1:10 sodium hypochlorite solution.

Use a large wad of paper towels so that the gloves do not
contact the liquid. Discard the towels after use.
Apply the disinfectant again. Leave the area wet for 10 mins
and then dry it with fresh paper towels.
Remove gloves carefully to avoid touching the contaminated
outside, and wash hands immediately. Wash, dry and autoclave
gloves after use.

Broken glass.
If contaminated broken glass or something sharp drops, do not
pick it up with the hands. Instead use tongs, forceps, or a
dustpan and brush.
Discard, clean and disinfect, or sterilize items used for this
purpose.
Broken glass or dropped sharps are discarded in the sharps
container.
After the sharp material has been removed, disinfect the area
as after a spill.

Discarding local anesthetic cartridges.
If the glass anesthetic cartridge is broken, pick up the
broken glass as previously described and discard the broken
glass with the sharps.
If the glass anesthetic cartridge is not broken and not visibly
contaminated with blood, discard it with other nonhazardous
waste.
If the glass anesthetic cartridge is visibly contaminated with
blood, discard it with regulated waste.

Laboratory specimens
Medical lab specimens, such as biopsy samples of
suspected oral cancerous lesions, to be transported
outside of the office for evaluation must be placed in
leakproof bags and labeled appropriately.
Dental impressions must also be placed in leakproof bags
and labeled appropriately.

Contaminated laundry
The dental personnel should either use disposable
uniforms or make arrangements for laundering or
professional cleaning of protective clothing.
Clothing dispatched to a commercial laundry should be
packed in red laundry bags, clearly labeled with a
biohazard symbol.

Mercury from dental amalgam.
 Placement and removal of dental amalgam restorations
generate amalgam waste particles that can be suctioned
into the dental unit vacuum line and discharged in to the
public sewer system.
Waste water treatment plants are facing increasing
pressure from environmental regulators .
treatment plants are looking to identifiable sources of
mercury or mercury containing waste .
Mercury compounds may be absorbed by organisms
and concentrated as they pass up the food chain.
But available data suggest that the solubility of the
metals in amalgam, in tap water or sewerage is very low.

Amalgam disposal.
Three aspects of amalgam waste may be considered.
Amalgam scrap.
Other waste contaminated with amalgam.
Amalgam in waste water.
Amalgam scrap: Is stored under radiographic fixer solution
in a covered container. Should be recovered and recycled
whenever possible. It is considered as hazardous waste with
chances of mercury leaching out of amalgam scrap. Hence
they should be disposed off as required for that of a regulated
waste and as per local regulations. It should not be disposed
with waste that would be eventually incinerated since
amalgam decomposes on heating.

Other waste contaminated with amalgam: like amalgam
capsules, extracted teeth with amalgam restorations, cotton
rolls and gauze with amalgam particles. Here again they should
not be incinerated and should be recycled or disposed off as
regulated waste in sealed leak proof bags.
Amalgam in waste water:
Chairside traps and vacuum pump filters.
Sedimentation tanks.
Electrical and chemical separation
Commercially available amalgam separators.

Amalgam separators
They are devices used to remove amalgam waste particles
in dental office discharge by several separation techniques,
either alone or in combination, like:
Sedimentation.
Filtration.
Centrifugation.
Ion exchange.

Management of mercury spills.
Never use a vacuum cleaner, broom or paintbrush or
household cleaning products like ammonia or chlorine.
Never allow mercury to go down the drain.
In case the shoes are contaminated with the spilt mercury,
the person is asked not to walk around or leave the spill area
until the contaminants are removed.
Sprinkling of sulfur powder on mercury spills has shown to
be ineffective and inadequate to control the problem,
because of the slow reaction.

Mercury spills are cleaned up properly by using trap bottle,
tapes, or fresh mixes of amalgam to pick up droplets, or use
commercial clean up kits.
If the floor carpeting in the operatory gets contaminated with
mercury, removal of the carpeting may be the only effective
way to ensure decontamination. Chemical decontamination of
the carpeting may be ineffective since mercury might seep
through the carpet and remain inaccessible to the
decontaminant.

Managing silver and lead waste.
Silver in used radiographic fixer solutions
Use of an in-office silver recovery unit to remover silver
from used fixer solutions and recycle the used cartridge.
Send used fixer solution to a silver reclaiming facility.
Send it to a medical radiology lab or a commercial
photographic processing lab, on agreement.
Lead foil in intraoral radiograph film packets.
Should be collected and recycled through a licensed
facility.
The same would apply to lead aprons and lead collars.

ON-SITE TREATMENT
Many areas allow in-house treatment of regulated
medical/dental waste. An easy and effective procedure is
sterilization by moist heat (autoclaving). Dry heat ovens
should not be used. Of course, the performance of the
sterilizer must be biologically monitored regularly.
Where allowed, sharps containers can be sterilized in-
house. The open containers should be placed into the
sterilizer in an upright position.

Recommendations Procedures for Sterilization of Sharps
Containers in Steam Autoclaves
1. 1.     Use only containers approved for the collection and storage of sharps and
which are autoclavable.
2. 2.     Biologically monitor the autoclave used on a regular basis (e.g., weekly).
3. 3.     Consider the following procedural recommendations:
4. a.      Fill containers no more than ¾ full
5. b.     Leave container vents open
6. c.     Place the containers in an upright position in the autoclave chamber
7. d.     Process containers for 60 minutes (e.g., two regular length cycles, unless a
single longer cycle can be used)
8. e.      Remove containers after processing and allow them to cool
9. f.       Carefully close container vents
10. g.     Label and dispose of containers according to local governmental regulations

In-house treated regulated waste items can then be added to
the non-regulated office waste. These items should be labeled
as “treated” or with other information as required by local laws.
Pathologic waste is considered to be potentially infectious and
must be regulated.
Teeth without amalgam restorations and other tissues can be
placed directly into a biohazard bag or a sharps container.
Where allowed, the waste can then be sterilized.
Teeth with amalgams could release mercury vapor during
sterilization, thus, they should be neutralized through
disinfection (ideally, immersion for 30 minutes in a fresh solution
of a tuberculocidal disinfectant held within a sealed container).
Treated teeth can then be rinsed with water and are ready for
disposal or returned to pediatric patients.

Items heavily soiled (even saturated) with blood/saliva can
be placed into a sharps container. However, it may be easier
to store them in small biohazard bags until treated. Used
anesthetic carpules should also be placed into sharps
containers.
TREATMENT OFF-SITE
Some areas may require regulated waste be removed,
neutralized, and disposed of by a commercial waste hauling
service, regulated by the local government.

Final disposal
Chemical decontamination can be carried out in a special
decontamination tank with drainage facilities and also a chain
and pulley block for loading/introducing operations of the large
buckets in which the waste are placed for decontamination.
Disposal of incinerator ash
The ash generated by the incinerator can be disposed of in an
Engineered Band fill which is chemically treated to prevent
seepage of metal into the earth. The ash generated by
incineration will contain mercury, arsenic, lead and cadmium all
heavy metals harmful to the human body.

The Bio-medical Waste (Management and Handling) (Second
Amendment) Rules, 2000 states the colour coding and type of container
for disposal of bio-medical wastes:
Colour
Coding
Type of Container -I Waste Category Treatment
options/disposal.
Yellow Plastic bag
Human Anatomical Waste, Soiled Waste
(Items contaminated with blood, and body fluids
including cotton, dressings, soiled plaster casts)
Incineration/deep
burial

Red Disinfected container/plastic bag
Soiled Waste
(Items contaminated with blood, and body fluids
including cotton, dressings, soiled plaster casts),
Solid Waste
(wastes generated from disposable items other
than the waste sharps such as tubings, catheters,
intravenous sets etc).
Autoclaving/Micro
waving/ Chemical
Treatment/shredding

Blue/White
Translucent
Plastic bag/puncture proof
Container.
Solid Waste
(wastes generated from disposable
items other than the waste sharps
such as tubings, catheters,
intravenous sets etc), Waste sharps
(needles, syringes, scalpels, blades,
glass, etc.)
Autoclaving/Micro waving/
Chemical Treatment and
destruction/shredding
Black Plastic bag
Discarded Medicines and
Cytotoxic drugs
(wastes comprising of outdated,
contaminated and discarded),
Chemical Waste
(chemicals used in production of
biologicals, chemicals used in
disinfection, as insecticides, etc.)
Disposal in secured landfill
chemical treatment and
discharge into drains for
liquids and secured landfill
for solids

CONTINGENCY PLANNING
It is best if offices prepare sets of written procedures
concerning their regulated waste. Such prepared programs
should always list the person or persons responsible in the
event of an emergency.
The success of any safety program is highly dependent on
proper employee training and employer monitoring. All
office personnel must be well versed in the handling,
storage, treatment, and disposal of regulated medical waste.

PUBLIC RELATIONS
A good portion of the population has an aversion to blood
(liquid or dried) and medical/dental sharps, especially
needles. Such anxiety also can exist among those charged
to collect, haul, and dispose of waste.
It would be best if properly treated and labeled regulated
waste containers were placed within some other type of
container (e.g., cardboard boxes) that can more readily
conceal the actual contents. This is an example of “out-of-
sight…out-of-mind.”

SUMMARY
Proper handling, neutralization, and disposal of regulated
dental waste are important elements of every dental office’s
infection control program. Correct procedures will help protect
office employees and patients, contract workers, and the local
community. An effective program is based on planning, which
includes a firm understanding of the regulations that apply in
their location. All office personnel must be knowledgeable as
to the correct procedures and the appropriate equipment. .

CONCLUSION
As producers of hazardous waste, dentists have a
responsibility and a duty of care for the correct management
of waste within their practice.
If properly designed and applied, regulated waste
management can be a relatively easy and inexpensive
venture, yet one that is also an effective and efficient
compliance-related practice.

REFERENCES.
 Council on dental materials and devices, Council on dental
therapeutics; Infection control in dental office; JADA 97;4:673-
677,Oct1978.
 Council on dental materials instruments and equipments,
Council on dental therapeutics and practice;Infection control
recommendations for the dental office and the dental
laboratory ; JADA: 116;Feb1988.
 Recommended clinical guidelines for infection control in dental
education institutions: Journal of Dental Education;55:9;1991.
 States act to regulate medical waste:JADA;122:Sep1991.
 P.L. Fan, Dorthe Arenholt-Bindslev;Environmental issues in
dentistry- mercury;International Dental Journal: 47;2:1997.
 Nairn H.F.Wilson,EdwardG.Bellinger;Dental practice and the
enviornment,International Dental Journal:48:3;161-166,1998.

 Amalgam in dental office wastewater,JADA: 133;585-
588;May2002.
 ADA Council on scientific affairs Managing silver and lead
waste in dental offices,,JADA,134:1095-1096;Aug2003.
 KEVIN. R. MCMANUS,P.L.FAN:Purchasing , installing and
operating amalgam separators- Practical issues;JADA;134,1054-
1065:Aug2003.
 ADA Council on scientific affairs Dental mercury hygiene
recommendations , :JADA;134,1498-1499;Nov2003.
 HAZEL. O. TORRES et al : Modern dental assisting 5th
edition .
 Clifford.M. Sturdevant et al :The art and science of
Operative dentistry 3rd
edition .
 Ann Ehrlich et al ; Essentials of dental assisting :2nd
edition.


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