Dental offices are subject to a variety of federal, state, and local regulations concerning the safe handling of their waste materials. Each federal regulatory or recommending agency (eg, EPA, OSHA, or CDC) has different charges from Congress. This article discusses how dental offices can manage regulated waste.
PLANNING
To be in compliance, dental offices must first be aware of all mandates concerning regulated waste applicable in their location. In addition to federal regulations, state and even local rules may apply. The process can be facilitated by the appointment of a properly trained office compliance officer. Such individuals can be responsible for establishing, monitoring, reviewing, and administering the office waste management plan.
Also needed are the generation of a written office procedures policy and the holding of adequate and regular employee training sessions. Issues addressing management of regulated waste can easily be incorporated into an office’s Exposure Control Plan.1,2
A regulated waste management plan contains a number of important components. These include designation, segregation, handling and storage, labeling, disposal, and 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. Hospital waste, dental office waste, or household waste refer to the total discarded solid waste generated by all sources within a given location.1-5 Infectious waste is a small subset (estimated to be 3% in hospitals and 1% to 2% in dental offices) of the total to be discarded.4-6 Infectious waste is that part of medical/dental waste that has been shown through controlled studies capable of transmitting an infectious disease. Infectious medical/dental waste is also known as regulated waste (as regulated by some governmental agency) because certain segregation, storage, and disposal procedures must be followed.1-6
There is no epidemiological evidence that the majority of medical/dental waste is any more infectious than residential waste. In other words, with the exception of a relatively limited number of items, medical/dental waste can be disposed of using regular waste removal and disposal schemes.
For dental offices, there are 5 types of regulated waste. These require special handling, storage, and disposal methods, and have been shown capable of transmitting infectious diseases. The 5 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 that readily release fluids during handling (by squeezing or are actually dripping or caked); (3) pathologic waste (eg, 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, and (5) potential sharps, such as anesthetic carpules that can contain aspirated blood and could break and cause injury and exposure.1,3,6,7
SEGREGATION
All waste from dental offices can be divided into 2 basic categories—regulated and nonregulated. 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. Segregation increases patient and practitioner safety and prevents contamination of nonregulated waste.1-6
The majority of soiled items are not regulated waste. For example, used gloves, masks, and gowns are not considered as regulated dental waste and thus can be added to the regular trash. The same is true for environmental barriers (eg, plastic bags or sheets and aluminum foil) used to cover equipment during treatment.1-6
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 be trained in appropriate handling, storage, and disposal methods.1,6
In response to a continuing concern about exposure, and the development of technological advances that increase employee protection, the US Congress passed the Needlestick Safety and Prevention Act in 2000. The act directs OSHA to revise its Bloodborne Pathogens Standard to establish in greater detail requirements that employers must identify and make use of effective and safer medical devices. More extensive training and record-keeping processes are also required. Enforcement of the new provisions in the Standard began on July 17, 2001.9,10
LABELING
Stored regulated waste must be placed into labeled or color-coded bags or containers. Usually such items are red and have biohazard symbols attached. Ideally, regulated wastes should be stored as soon as possible with a minimum of transport.1-6
Regulated waste must be stored in a properly ventilated, secured area that patients cannot readily see. Generally, waste should not be stored for more than 30 days. Waste containers must be designed to prevent the development of offensive odors.1-6
DISPOSAL
In most locations, blood in a liquid or semi-liquid form, even when mixed with other fluids such as saliva, can be poured or evacuated into the office waste water system. Sink traps and evacuation lines should be thoroughly rinsed at least daily and treated with an effective, environmentally compatible disinfectant or evacuation cleaner. A final water rinse should follow.1,3,6
Many areas allow in-house treatment of regulated medical/dental waste. An easy and effective procedure is sterilization by moist heat (autoclaving). Of course, the performance of the sterilizer must be biologically monitored regularly.1-6 The open containers should be placed into the sterilizer in an upright position. Fill the container only three-fourths full. Run the containers through 2 consecutive treatment cycles. In-house treated regulated waste items can then be added to the nonregulated office waste. These items should be labeled as “treated” or with other information as required by local laws.1-6
Pathologic waste is considered as being potentially infectious and thus 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 return to pediatric patients.1-6
Items heavily soiled (even saturated) with blood/saliva can be placed into sharps containers. However, it may be easier to store them in small biohazard bags until treated. Used anesthetic carpules should be placed into sharps containers.3,6,7
Some areas require that regulated waste be removed, neutralized, and disposed of by a commercial waste hauling service. Some offices use such services for “peace of mind.” However, several questions must be addressed. Is the service an EPA approved hauler? Will I receive a receipt every time my waste is collected? Will I receive an official manifest within 30 days of a pickup, which indicates the procedures used to neutralize my waste, the location of the operation, and location of final disposal? What is my liability after the waste has left my office?
PUBLIC RELATIONS
A significant 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. In extreme cases, haulers have refused to remove regulated medical waste, especially needles.3,6,7
It would be best if properly treated and labeled regulated waste containers were placed within some other type of container (eg, cardboard boxes) that can more readily conceal the actual contents. This is an example of “out of site…out of mind.” The overall security of dumpster boxes, however, is the responsibility of the hauler.
References
1. US Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910.1030 – Bloodborne Pathogens. Occupational exposure to bloodborne pathogens; needlestick and other sharps injuries, final rule. Federal Register, 2001; 66 (12):5317-5325. As amended from and including Federal Register 1991;29 CFR Part 1910.1030. Occupational exposure to bloodborne pathogens, Final rule. 56 (235): 64174-64182, 1991. Available at: osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=100. Accessed: March 10, 2004.
2. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings 2003. MMWR. December 19, 2003;52(RR-17):1-68.
3. Palenik CJ. Managing regulated waste in dental environments. J Contemp Dent Pract. 2003;4(1):76-88.
4. Gordon JG and Denys GA. Infectious wastes: efficient and effective management. In: Block SS, ed. Disinfection, Sterilization and Preservation. 5th ed. Philadelphia, Pa: Lea & Febiger; 2001:1139-1157.
5. Hedrick E. Infectious waste management. In: APIC Text of Infection Control and Epidemiology. Washington, DC: APIC; 2000:74-117.
6. Palenik CJ, Miller CH. Infection Control and Management of Hazardous Materials for the Dental Team. 3rd ed. St. Louis, Mo: Mosby; 2004:177-188.
7. ADA Council on Scientific Affairs and Council on Dental Practices. Infection control recommendations for the dental office and the dental laboratory. J Am Dent Assoc. 1996;127:672-680.
Dr. Palenik has held over the last 25 years a number of academic and administrative positions at Indiana University School of Dentistry. These include professor of oral microbiology, director/human health and safety, director/central sterilization services, and chairman/infection control and hazardous materials management committees. Currently he is director/infection control research and services. Dr. Palenik has published 125 articles, more than 290 monographs, 3 books, and 7 book chapters, the majority of which involve infection control and human safety and health. Also, he has provided more than 100 continuing education courses throughout the United States and 8 foreign countries. All questions should be directed to OSAP by e-mail at office@osap.org.
