EPA Proposes Amalgam Separator Rule
Nationwide rule requires amalgam separators in every office
In an effort to reduce the discharge of dental amalgam into the environment, the U.S. Environmental Protection Agency (EPA) recently proposed a rule under the Clean Water Act requiring dentists to install amalgam separators.
Studies show that half of the mercury that enters publicly owned treatment works originates from dental amalgam. Tiny particles of amalgam can bypass chairside traps every time an amalgam filling is placed or removed. After water treatment, mercury is distributed back in the form of precipitation and consumed by fish, making its way into our food chain.
The proposed rule would require all affected dentists to control mercury discharges to publicly owned treatment works. Specifically, it would require them to cut their dental amalgam discharges to a level achievable through the use of amalgam separators and the use of other best management practices. The EPA expects compliance with this proposed rule would cut metal discharge to treatment works, half of it from mercury, by at least 8.8 tons a year.
“The rule would strengthen human health protection by requiring removals based on the use of a technology and practices that approximately 40% of dentists across the country already employ”
– Kenneth Kopocis, Deputy Assistant Administrator for the EPA’s Office of Water
The rule would allow dentists to show they are in compliance by installing, operating, and maintaining an amalgam separator. However, if the existing separators in a dental practice do not remove the percentage of amalgam in the proposed requirements, a practice can still be ruled as compliant for the life of the existing separator. Finally, it would limit dental dischargers’ reporting requirements to annual certification and record-keeping instead of wastewater monitoring.
The EPA will accept public comments on the proposal for 60 days following publication in the Federal Register. A public hearing also is scheduled for November 10. The agency expects to finalize the rule in September 2015.
Easy ways to avoid harmful x-ray exposure
Dental x-rays are critical to evaluating and diagnosing many oral diseases and conditions. Although radiation exposure from x-rays is low, the effects can accumulate from multiple sources over time. Limiting radiation exposure can be achieved through these simple techniques:
PROTECTING THE PATIENT
Obtaining and reviewing previous full-mouth series or panoramic x-rays can eliminate the need to take new radiographs. For example, patients with stable periodontal health and a low caries rate may be able to increase the time between bitewings from annually to every 18 to 24 months years (ADA, 2012). If new radiographs are necessary, radiation exposure can be decreased through the use of higher film speeds, shielding, and collimation.
HIGHER FILM SPEEDS: Using the fastest film available significantly reduces radiation exposure. Currently, intraoral X-ray film is available in three speeds: D, E, and F. E-speed film is almost twice as fast as D-speed film—and about 50 times faster than traditional x-ray film. F-speed film requires about 25% less exposure than E-speed film and 60% less exposure than D-speed film. Multiple studies have confirmed that F-speed film has the same useful density range, latitude, contrast, and image quality as D- and E-speed films, and it can be used in routine intraoral radiographic examination without sacrificing diagnostic information (ADA, 2012).
SHIELDING: The use of aprons and thyroid collars shields the gonads and thyroid gland from radiation exposure, which is particularly important among vulnerable populations, such as children and pregnant women. The ADA recommends that every patient should be covered with an apron. When taking routine bitewing and periapical radiographs, a thyroid collar should be used. Panoramic imaging is an exception to the rule; a thyroid collar can obscure large areas of the target zone (ADA, 2012).
COLLIMATION: A collimator is a metallic barrier with an opening in the middle that is used to reduce the size of the x-ray beam, and, thus, the exposure area. Dental x-ray beams are usually collimated to a circle 2¾” in diameter. When an x-ray beam is directed at a patient, the hard and soft tissue absorbs about 90% of the photons, while approximately 10% passes through the patient and reaches the film (ADA, 2012).
PROTECTING THE OPERATOR
Although dental professionals receive less exposure to ionizing radiation than do other occupationally-exposed healthcare workers, operator protection measures are essential to minimize exposure. Protective measures include the use of barrier shielding, occupational radiation exposure limits, and personal dosimeters.
SHIELDING: When possible, operators of radiographic equipment should use barrier protection, and barriers should ideally contain a leaded glass window to enable the operator to view the patient during exposure. When shielding is not possible, the operator should stand at least two meters from the tube head and out of the path of the primary beam.
EXPOSURE LIMITS & PERSONAL DOSMITERS: The maximum permissible annual dose of ionizing radiation for health care workers is 50 millisieverts (mSv) and the maximum permissible lifetime dose is 10 mSv multiplied by a person’s age in years. Personal dosimeters must be used by workers who may receive an annual dose greater than 1 mSv to monitor their exposure levels. Pregnant dental personnel operating x-ray equipment must also use personal dosimeters, regardless of anticipated exposure levels (ADA, 2012).
PureLife now offers personal dosimeters that measure the amount of high energy ionizing radiation a person has been exposed to. The PureLife Radiation Detection Badge is a small, reliable badge designed for superior accuracy, easy handling and cleanliness.
Keeping Up with Waste Compliance
It’s as easy as 1-2-3…
Keeping up with waste compliance can be confusing and expensive. With dental offices subject to numerous regulations at the federal, state, and local level, knowing which compliance protocols are applicable to your practice isn’t easy. Not to mention, waste is a broad category comprised of a variety of issues that lack actionable solutions. Thankfully, compliance is easier to achieve than it seems. Here’s a breakdown of key waste compliance issues in terms of their (a) problems, (b) regulations, and (c) solutions:
1. Bio-Hazard and Sharps Waste
THE PROBLEM: Many dental practices opt for a waste disposal pickup service that is unknowledgeable of dental regulations. As a result, dentists may be locked into confusing contracts without a point of contact that understands their compliance needs–leaving dental professionals responsible for understanding their requirements or risk non-compliance.
THE REGULATIONS: Specifics concerning bio-hazard and sharps regulations vary by state, with each state requiring one of these disposal practices:
- Both sharps and soft waste are to be disposed of after a designated time limit
- Both sharps and soft waste are to be disposed of once the container is full
- Only sharps are to be disposed of once the container is full and soft waste is to be disposed of after designated time limit
THE SOLUTION: Mail-back systems are a convenient and cost-effective alternative to pickup services. Ranging from 1-quart to 30-gallon containers, these mail-back systems eliminate the use of costly pickup services and include a prepaid return shipping box that allows for complete tracking and documentation. When ready, simply place your container in the prepaid return box and leave it to be picked up along with the rest of your packages.
2. Mercury Waste
THE PROBLEM: Much of the mercury that enters our wastewaters originates from dental amalgam. Tiny particles of amalgam can bypass chairside traps every time an amalgam filling is placed or removed. After water treatment, mercury is distributed back in the form of precipitation and consumed by fish, making its way into our food chain.
THE REGULATIONS: At least 12 states and numerous localities have mandatory mercury pretreatment programs in place. At the federal level, the EPA recently announced that it would be formulating a nationwide rule regulating disposal methods for dental amalgam. This rule is expected to be finalized in the near future.
THE SOLUTION: It is possible to eliminate mercury pollution by installing an amalgam separator. Installation is extremely simple and allows dentists to eliminate 99% of their mercury waste, and maintenance usually involves replacing the canister once it’s full, generally every 6-12 months.
3. X-Ray Waste
THE PROBLEM: Dental offices generate many different forms of waste as a result of traditional x-ray processing that can have a serious impact on wastewaters and soil.
THE REGULATIONS: The disposal of used fixer is strictly regulated nationwide due to its high toxicity level. However, many regulations can vary significantly by location. To determine your waste disposal requirements, contact your local OSHA office, wastewater treatment agency, or state dental association.
THE SOLUTION: X-ray waste can be prevented from entering the environment by implementing an x-ray waste collection and recycling program. This includes capturing lead waste in an approved UN/DOT storage container, filtering used fixer via a photo chemical filter to remove silver content, and recycling x-ray film. The optimal solution is to shift to a digital x-ray system.
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A Comprehensive Look at Dental Unit Waterlines
Eliminating the risk of contamination requires going beyond the status quo
In 2011, the dental industry received international attention when an 82 year old Italian woman died from a case of Legionnaire’s disease she contracted during dental treatment—its source traced to contaminated water from dental unit waterline tubing.
A Perfect Storm for Biofilm
Bacterial biofilm is virtually universal in untreated dental unit waterlines and can begin forming in a new dental unit within days. Although there has only been a handful of reported cases of dental waterline contamination since 1963, many microorganisms of concern have been isolated from dental unit water, namely Pseudomonas species, non-tuberculosis mycobacteria, and Legionella, the causative agent of Legionnaires’ disease. Legionella poses a particular threat because it can be transmitted by inhaling aerosols or aspirating water contaminated with the bacteria. Because of their narrow tubing (1/8” to 1/16”), dental waterlines provide particularly well-suited conditions for biofilm–a community of bacteria and other microbes that adhere to surfaces and form a protective slime layer. Low water pressure, low flow rates, and frequent periods of stagnation also encourage any bacteria introduced from municipal water to accumulate within the tubing.
Anomalies of Waterline Testing
According to the American Dental Association (ADA) Council on Scientific Affairs’ 1999 report to the profession on dental unit waterlines, evaluating water quality before a treatment protocol is implemented is controversial. Because the scientific literature suggests that all units are highly contaminated, pre-testing to confirm contamination is of questionable value. However, testing water quality after initiation of a treatment regimen ascertains whether a waterline product or protocol achieves the desired outcome. Monitoring water quality according to an established schedule can help identify problems in performance or compliance and provide documentation of water quality.
Waterline Monitoring Recommendations
Both in-office monitoring devices and commercial testing services are available. Dentists should consult with the manufacturer of their dental unit or water delivery system to determine the best method for maintaining acceptable water quality (i.e.,
Waterline Treatment Options
FLUSHING: Mechanical flushing alone does little to control contamination in waterlines. Although it can temporarily reduce the number of microbes in the water delivered to patients by clearing away many of the free-floating organisms in the waterline, biofilm bacteria continually break free and recontaminate dental unit water during the course of clinical treatment. Flushing for several minutes between patients, however, may be valuable in removing contaminants that can enter the water system during patient treatment.
SELF-CONTAINED WATER SYSTEMS: Also referred to as independent water systems or reservoirs, these isolate the dental unit from the municipal water supplies, instead providing water or treatment solution from reservoirs filled and maintained by office staff. They allow the practice to control the quality of water that is used in the unit.
CHEMICAL DISINFECTANTS: A number of chemicals are reported to inactivate or prevent biofilm, whether through periodic (intermittent or “shock” treatment) or continuous presence in the waterline. Periodic disinfection involves purging the waterlines, adding a chemical to the water reservoir, filling the lines for the recommended time period, and flushing. Continuous chemical treatment refers to waterline treatment via an irrigant/coolant solution or the use of automated metering devices. Metering devices release low levels of chemical germicide into the treatment water to control biofilm to lower bacterial counts in the water. Some products may require both intermittent and continuous line treatments to maintain water quality.
No matter the treatment option you implement in your practice, strict compliance with the recommended treatment regimen is the key to consistent water quality.