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FAQ's Waste Treatment & Disposal

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Q When a patient vomits, since this is OPIM, it should be discarded with our infectious waste, correct? Is there any documentation of this?

Q We have been following the CDC Guidelines for Infection Control in Dental Healthcare Settings regarding regulated waste vs. non-regulated waste. Gauze, cotton rolls, gloves, etc. that were used during the patient visit, but are not saturated or soaked with blood or saliva, are being discarded in regular waste. However, during a recent visit by our University's Environmental Health and Radiation Safety Office, we were instructed to dispose of everything that has been in contact with the patient during the course of treatment in the red containers. They sighted the OSHA definition of regulated waste which can be interpreted both ways. Please clarify. By following the CDC guidelines, are we non-compliant with the OSHA regulations?

Q What is the updated protocol for handling hazard waste spills on floors in the office such as mercury and amalgam? We have a spill kit but want to make sure we are following procedures.

Q We recently purchased some new lead shields at our office. How do we properly dispose of the olds ones?

Q What is the best way to store scrap amalgam?

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Q When a patient vomits, since this is OPIM, it should be discarded with our infectious waste, correct? Is there any documentation of this?

A Under OSHA's Bloodborne Pathogens Standard 29 CFR 1910.1030 only blood and certain body fluids are considered regulated waste or other potentially infectious materials. It should be noted that under Universal Precautions OSHA does not list vomit as OPIM. However, OSHA states that it is the employer's responsibility to determine the existence of regulated waste.

Disposal of all regulated waste shall be in accordance with applicable regulations of the United States, States and Territories, and political subdivisions of States and Territories.

The Standard defines the following terms:

Universal Precautions is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens. (1)

Regulated Waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials. (1)

Other Potentially Infectious Materials means (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV. (1)

According to the authors of Infection Control & Management of Hazardous Materials for the Dental Team, the prevailing view is that no epidemiologic evidence suggests that most medical waste is any more infective than residential waste. Also, no epidemiologic evidence indicates that current medical/dental waste handling and disposal procedures have caused disease in the community. Therefore, identifying wastes for which special precautions are necessary is largely a matter of judgment concerning the relative risk of disease transmission. (2)

What now is agreed commonly is that only a limited amount of medical waste needs to be regulated (requiring special handling, storage, and disposal methods). For dentistry, these items include bulk blood or blood products, pathology waste, and sharps. Often the blood and blood products group is expanded to include liquid or semi-liquid blood (and any other potentially infectious materials), contaminated items that release liquid or semi-liquid blood or other potentially infectious materials when compressed items caked with dried blood or other potentially infectious materials that could be released during handling, and pathologic or microbiologic wastes that contain blood or other potentially infectious materials. Usually other body fluids are exempt. However, the CDC considers saliva to be infectious waste because it often is tainted with blood during treatment. Fortunately for dentistry, the generation of infectious waste items is modest. (2)

Based on CDC's Standard Precautions, all blood and body fluids, including secretions and excretions (except sweat), should be considered as potentially infectious in all patients.

With regard to the clean up of vomit, blood, saliva, body fluids, and OPIM (other potential infectious materials), we will refer you directly to the Centers for Disease Control and Prevention's Infection Control Guidelines for Dental Healthcare Settings. Although the guidelines do not specifically address vomit, the following is applicable:

The relevance of universal precautions to other aspects of disease transmission was recognized, and in 1996, CDC expanded the concept and changed the term to standard precautions. Standard precautions integrate and expand the elements of universal precautions into a standard of care designed to protect HCP and patients from pathogens that can be spread by blood or any other body fluid, excretion, or secretion (11). Standard precautions apply to contact with 1) blood; 2) all body fluids, secretions, and excretions (except sweat), regardless of whether they contain blood; 3) nonintact skin; and 4) mucous membranes. Saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between universal precautions and standard precautions. (3)

Cleaning and Disinfection Strategies for Blood Spills

The majority of blood contamination events in dentistry result from spatter during dental procedures using rotary or ultrasonic instrumentation. Although no evidence supports that HBV, HCV, or HIV have been transmitted from a housekeeping surface, prompt removal and surface disinfection of an area contaminated by either blood or OPIM are appropriate infection-control practices and required by OSHA. (3)

Strategies for decontaminating spills of blood and other body fluids differ by setting and volume of the spill. Blood spills on either clinical contact or housekeeping surfaces should be contained and managed as quickly as possible to reduce the risk of contact by patients and DHCP. The person assigned to clean the spill should wear gloves and other PPE as needed. Visible organic material should be removed with absorbent material (e.g., disposable paper towels discarded in a leak-proof, appropriately labeled container). Nonporous surfaces should be cleaned and then decontaminated with either an EPA-registered hospital disinfectant effective against HBV and HIV or an EPA-registered hospital disinfectant with a tuberculocidal claim (i.e., intermediate-level disinfectant). If sodium hypochlorite is chosen, an EPA-registered sodium hypochlorite product is preferred. However, if such products are unavailable, a 1:100 dilution of sodium hypochlorite (e.g., approximately ¼ cup of 5.25% household chlorine bleach to 1 gallon of water) is an inexpensive and effective disinfecting agent. (3)

Carpeting and Cloth Furnishings

Carpeting is more difficult to clean than nonporous hard-surface flooring, and it cannot be reliably disinfected, especially after spills of blood and body substances. Studies have documented the presence of diverse microbial populations, primarily bacteria and fungi, in carpeting. Cloth furnishings pose similar contamination risks in areas of direct patient care and places where contaminated materials are managed (e.g., dental operatory, laboratory, or instrument processing areas). For these reasons, use of carpeted flooring and fabric-upholstered furnishings in these areas should be avoided. (3)

Resource:

1) OSHA: Bloodborne Pathogens Standard 29 CFR 1910.1030

http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051

2) Infection Control & Management of Hazardous Materials for the Dental Team, 3rd. Edition. By
Miller and Palenik. Elsevier/Mosby Publishers. Copyright 2005.

3) Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental
Healthcare Settings:

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

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Q We have been following the CDC Guidelines for Infection Control in Dental Healthcare Settings regarding regulated waste vs. non-regulated waste. Gauze, cotton rolls, gloves, etc. that were used during the patient visit, but are not saturated or soaked with blood or saliva, are being discarded in regular waste. However, during a recent visit by our University's Environmental Health and Radiation Safety Office, we were instructed to dispose of everything that has been in contact with the patient during the course of treatment in the red containers. They sighted the OSHA definition of regulated waste which can be interpreted both ways. Please clarify. By following the CDC guidelines, are we non-compliant with the OSHA regulations?


A Because state and local regulations/laws vary among states, OSAP is not in a position to determine whether or not your facility would be non-compliant with the OSHA Standards.

While we can provide you with general information that may assist you in understanding your University's requirement, the University's Environmental Health and Radiation Safety Officer is in a better position to explain all applicable regulations/laws in your state and the rationale for requiring all patient contaminated waste to be disposed of in red containers. The Safety Officer may also contact your state OSHA office and county public health department for clarification of local regulations.

The Centers for Disease Control and Prevention (CDC) guidelines are superseded by federal, state, and local regulations/laws. In addition, states with state operated OSHA plans must enforce the Federal Standards, however, state plans may have stricter interpretations of the Standards. The federal, state, and local Environmental Protection Agency (EPA) also regulates waste disposal, including waste generated by dental facilities. Although differences among federal agencies concerning the definition of infectious medical waste have narrowed, these definitions may be superseded (additional soiled items included) by some states and local jurisdictions.

OSHA regulates waste while it remains inside the facility. After regulated waste leaves the facility, the transport and ultimate disposal of hazardous waste is regulated by the EPA.

OSHA defines regulated waste as: Regulated Waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials. (1)

The authors of OSAP's Interact Infection Control and Safety Training System state: waste that has had contact with blood or other body secretions may be considered contaminated waste. Contaminated waste, in most states, is eventually disposed of as general waste. Some states, however, may consider and define contaminated waste as regulated waste. (2)

According to the authors of Infection Control & Management of Hazardous Materials for the Dental Team, the CDC guidelines make two recommendations for general medical waste. First, a medical waste management program for the practice needs to be developed. This written program must follow federal, state, and local regulations. Second, dental practices also need to ensure that all personnel who handle and dispose of potentially infective waste are trained in appropriate methods and that they are informed of the possible safety and health hazards. (3)

Resources:

1) OSHA's Bloodborne Pathogens Standard 29 CFR 1910.1030

OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030

2) OSAP's Interact Infection Control and Safety Training System. By Eklund and Bednarsh. Copyright 1999.

3) Infection Control & Management of Hazardous Materials for the Dental Team. Third
Edition. By Miller and Palenik. Elsevier Mosby Publishers. Copyright 2005.


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Q What is the updated protocol for handling hazard waste spills on floors in the office such as mercury and amalgam? We have a spill kit but want to make sure we are following procedures.

A OSAP does not maintain individual state/local regulations/laws and can only provide you with general information.

OSHA's Hazardous Communication Standard 29 CFR 1910.1200 involves hazardous chemicals in the workplace and applies to dentistry. The Standard requires each facility to have a written chemical hygiene plan. The written chemical hygiene plan must be communicated to each employee and provide procedures for evacuation, medical care, incident reporting, and clean up of spills. Thus, dental offices utilizing amalgam are required to have a mercury spill kit available.

Chemical spills should be handled and cleaned-up according to the product's Material Safety Data Sheet (MSDS) and disposed of according to all federal, state, and local laws. As a general rule, a minimum of two types of spill kits should be available to handle chemical spills in a dental setting: 1) general all purpose chemsorb kit and 2) mercury spill kit.

You should contact your state and local EPA agency, State Dental Society/Association, and State Board of Dental Examiners/Licensing Board to inquire about applicable laws in your area. Because elemental mercury may not be poured down the drain or disposed of in waste receptacles, these agencies often maintain a list of qualified waste haulers/recyclers in your area.

With regard to scrap amalgam, again all federal, sate, and local regulations/laws apply with regard to disposal of amalgam waste including empty amalgam capsules.

The American Dental Association (ADA) has revised their recommendations concerning amalgam waste. The ADA's Best Management Practices For Amalgam Waste (March 2004) recommends that disposable amalgam capsules be recycled and not disposed of in biohazard containers, infectious waste containers (red bags) or regular garbage. The ADA offers suggestions that include several steps that can be taken with regard to disposable amalgam capsules. The suggestions may be viewed in the Best Management Practices For Amalgam Waste. (1) (2)

Again, these are only ADA recommendations and all federal, state, and local regulations/laws must be adhered to.

Scrap Amalgam

Salvage and store all contact and non-contact scrap amalgam in separate, appropriately labeled, tightly closed containers. (3)

Recycle scrap amalgam through an amalgam recycler. (3)

Follow the requirements of your amalgam recycler for the storage, disinfection and shipping of scrap amalgam. (3)

It is also important to keep in mind that the specific type and number of spill kits that the facility must make available is based on the information provide on the chemical's MSDS. Typically, section VII of the MSDS should include precautions for safe handling and use, including spill and/or leak procedures. This section gives details concerning the use of protective clothing, equipment, and ventilations to be used for cleaning up a spill and safe disposal of the chemical.

Additionally, if you are unable to locate the instructions for the spill kit you should contact the product's manufacturer and obtain replacement instructions.

OSHA provides materials to assist facilities in establishing and writing the required hazardous communication program. The following resources should be useful to you.

1) The Hazardous Communication Standard may be viewed at:

http://www.osha.gov/SLTC/hazardcommunications/index.html

2) OSHA provides model Hazardous Communication Programs and Examples that may be viewed at: http://www.osha.gov/SLTC/hazardcommunications/solutions.html

3) OSHA also provides a great deal of information that explains the hazard communication requirements that may be viewed at:

http://www.osha.gov/SLTC/hazardcommunications/whatishazcom.html

4) OSHA provides specific information concerning mercury that may be viewed at:

http://www.osha.gov/SLTC/mercury/index.html

5) OSHA Publications may be obtained and viewed at:

http://www.osha.gov/pls/publications/pubindex.list

(Publication numbers 3084, 3114, 174, 3187, and 3186 should be most useful).

6) OSHA provides information for dentistry that may be viewed at:

http://www.osha.gov/SLTC/dentistry/index.html

Additional resources that may be useful include the following:

1) The American Dental Association has a great deal of information on management of amalgam waste, including mercury hygiene recommendations that may be viewed at;

http://www.ada.org/prof/resources/topics/amalgam_bmp.asp

The ADA also provides a directory of dental waste recyclers that is available at:

http://www.ada.org/prof/resources/topics/topics_amalrecyclers.pdf

2) OSAP has links to State Agencies at:

http://www.osap.org/resources/links

3) OSAP's April 2006 issue of Infection Control In Practice: Where Are Your MSDSs?: Vol. 5, No. 3, may also be beneficial to you (available on-line to OSAP members).

4) Cornell University Office of Environmental Health and Safety:

http://www.med.cornell.edu/ehs/faq/chemical_safety.htm

5) Seton Compliance Resource Center:

http://www.setonresourcecenter.com/safety/spill

6) With regard to mercury, silver, and other dental waste disposal, The Environmentally Responsible Dental Office: A Guide to Proper Waste Management in Dental Offices. Northeast Natural Resource Center of the National Wildlife Federation and the Vermont State Dental Society. June 1999, may be viewed at (ADA makes reference to this material):

http://www.delta-institute.org/pollprev/mercury/linkfiles/VTdentalguide.pdf

Resources:

1) ADA's Best Management Practices For Amalgam Waste:

http://www.ada.org/prof/resources/topics/topics_amalgamwaste.pdf

2) The ADA statement concerning amalgam:

http://www.ada.org/prof/resources/topics/amalgam_bmp.asp

3) The Environmentally Responsible Dental Office: A Guide to Proper Waste Management in Dental Offices. Northeast Natural Resource Center of the National Wildlife Federation and the Vermont State Dental Society. June 1999.

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Q We recently purchased some new lead shields at our office. How do we properly dispose of the olds ones?

A First and foremost, lead must be disposed of according to all federal, state, and local laws/regulations. OSAP does not maintain state/local laws, or regulations, therefore, check with your State Environmental Protection Agency—solid waste division (EPA) and State Board of Dental Examiners/Licensing Board for current federal, state, and local regulations governing lead disposal in your state. There also may be state and local health regulations (due to the lead content) that OSAP would not be aware and your State Health Department/Agency should be contacted as well. You may also contact a licensed waste hauler in your area for additional information on proper disposal.

Typically, lead should be segregated and placed in a clearly labeled lead waste container to await disposal or recycling by a properly licensed waste hauler. But again, lead must be handled and disposed of according to your state/local laws.

OSAP provides links to individual state agencies at: http://www.osap.org/resources/links

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Q What is the best way to store scrap amalgam?

A All Federal, State, and Local regulations/laws apply with regard to disposal of amalgam waste including empty amalgam capsules. OSAP does not maintain individual state/local regulations/laws and can only provide you with general information. You should contact your state and local EPA agency, State Dental Society/Association, and State Board of Dental Examiners/Licensing Board to inquire about applicable laws in your area.

OSAP has links to State Agencies at:

http://www.osap.org/resources/links

The American Dental Association (ADA) has revised their recommendations concerning amalgam waste. The ADA's Best Management Practices For Amalgam Waste (March 2004) recommends that disposable amalgam capsules be recycled and not disposed of in biohazard containers, infectious waste containers (red bags) or regular garbage. The ADA offers suggestions that include several steps that can be taken with regard to disposable amalgam capsules. The suggestions may be viewed in the Best Management Practices For Amalgam Waste. (1) (2)

Again, these are only ADA recommendations and all Federal, State, and Local regulations/laws must be adhered to.

Scrap Amalgam

Salvage and store all contact and non-contact scrap amalgam in separate, appropriately labeled, tightly closed containers. (3)

Recycle scrap amalgam through an amalgam recycler. (3)

Follow the requirements of your amalgam recycler for the storage, disinfection and shipping of scrap amalgam. (3)

Resources:

1) ADA's Best Management Practices For Amalgam Waste may be viewed at:

http://www.ada.org/prof/resources/topics/topics_amalgamwaste.pdf

2) The ADA has a great deal of information concerning amalgam. Links to this information is
located at:

http://www.ada.org/prof/resources/topics/amalgam_bmp.asp

3) The Environmentally Responsible Dental Office: A Guide to Proper Waste Management in Dental Offices. Northeast Natural Resource Center of the National Wildlife Federation and the Vermont State Dental Society. June 1999.

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