Review Article Best management practices for hazardous dental waste disposal RAJARAM NAIK * SURESHCHANDRA B. * SRINIDHI HEGDE ** AFTAB DAMDA ** MEETA MALIK *** ABSTRACT Proper handling, treatment and disposal of biomedical wastes are important elements of health care office infection control programme. Properly designed and applied, waste management can be a relatively effective and an efficient compliance-related practice. Some waste from healthcare facilities, however, is contaminated. If not disposed of properly, contaminated wastes may carry microorganisms that can infect the people who come in contact with the waste as well as the community at large. Keywords: Waste Management, Hazardous Waste, Infection Control. Government of India under its gazetted notification from the Ministry of Environment and Forests informed to all concerned that no one can dispose any kind of waste, general or bio-medical waste in the open. Disposal of harmful waste produced by dentists and clinics can pollute the environment. Dental biomedical waste disposal in the road side bins can infect the municipal waste collectors if they are not properly protected. In view of this most nations have introduced best management practices for hazardous dental waste disposal. Bio-medical waste is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities. It may include wastes like sharps, soiled waste, disposables, anatomical waste cultures, discarded medicines, chemical wastes etc. This waste is potentially hazardous, the main hazard being infection, and may pose a serious threat to human health if management is indiscriminate and unscientific.proper collection and segregation of biomedical waste are important. At the same time, the quantity of waste generated is equally important. A lesser amount of biomedical waste means a lesser burden on waste disposal work, cost-saving and a more efficient waste disposal system. The surveys carried out by the Central Board and various other agencies indicated that the health care establishments in India were not given due attention to their waste management. It did not form an integral part of their health care program. The negligence on the part of the health care establishment was reflected in various articles in the newspapers and a public interest litigation in the Supreme Court. Realizing the gravity of the * Professor, ** Reader, *** Post Graduate Student. Department of Conservative Dentistry & Endodontics, A.J. Institute of Dental Sciences, Mangalore. 108
RAJARAM NAIK, SURESHCHANDRA B., SRINIDHI HEGDE, AFTAB DAMDA, MEETA MALIK issue, the Central Board took up the matter, in right earnest, with the Ministry of Environment and Forests. This led to the notification of Bio-medical waste (Handling and management) Rules, 1998. Now that there is legal binding on the health care establishments, the state government is slowly streamlining the process of waste segregation, collection, treatment and disposal. POLICIES AND PROCEDURES: (a). Strategies for minimizing the quantities of biomedical waste generated and disposed of; (b). Methods of segregating, packaging, labelling, moving, storing, treating, and transporting the various waste types. (Both on- and off-site, as appropriate); (c). Methods for keeping records of the quantities of biomedical waste generated, treated, and disposed of; (d). A list of all regulations and legislation concerning biomedical waste that are applicable in the facility s jurisdiction. (e). A list of those responsible for managing biomedical waste in the event of an accident or spill; and (f). Provision for regular, ongoing staff instruction about proper handling and potential hazards of biomedical waste. Certain basic elements must be embodied in any biomedical waste management program to ensure that biomedical waste is handled and disposed off safely and efficiently. COLOUR AND TYPE OF CONTAINER FOR DISPOSAL OF BIO-MEDICAL WASTES Colour Coding Type of Container Waste Yellow Plastic Bag Cat. 1, Cat. 2, Cat. 3, Cat. 6 Incineration / deep burial Red Disinfected Container / Plastic Bag Cat. 3, Cat. 6, and Cat. 7 Autoclaving / Microwaving Chemical Treatment Blue / White Translucent Plastic Bag / Puncture Proof Container Cat. 4 and Cat. 7 Autoclaving / Microwaving Chemical Treatment and Destruction / Shredding Black Plastic Bag Cat. 5 and Cat. 9, Cat. 10 (Solid) Disposal in Secured Landfill A. NON-ANATOMICAL WASTES (BLOOD SOAKED MATERIALS) All biomedical wastes must be colour coded and marked with the Workplace Hazardous Material Information System (WHMIS) biohazard symbol. Biomedical wastes can only be transported by a company with proper certification. Biomedical wastes are also occupational health and safety concerns for those who come in contact with them. Non-dripping gauze and extracted teeth are not considered biomedical; however teeth with amalgam restorations cannot be placed in the incinerator for disposal. BEST MANAGEMENT PRACTICE (BMP) Use a yellow biomedical waste bag to collect the non-anatomical wastes and then double bag 109
BEST MANAGEMENT PRACTICES FOR HAZARDOUS DENTAL WASTE DISPOSAL the waste, label the bag with a biohazard symbol. Keep refrigerated if onsite for more than 4 days. Once accumulated, contact a certified biomedical waste carrier for disposal. These bags are available from your biomedical waste carrier and your dental equipment supplier. in this container. Do not fill over -full to prevent injury. Do not dispose the syringes and needles as it is. Always cut the needle with a needle cutter and dispose it otherwise the rag pickers are likely to pick up these syringes and needles and it gets recirculated into the main stream. Never throw blood soaked materials into the regular garbage or into the compost waste and never place them in the sharps container. NON-ANATOMICAL WASTES All sharps must be disposed using the appropriate guidelines. Proper disposal will minimize possible puncture wounds on other workers handling these wastes such as cleaners and waste carriers. NEEDLE DISPOSAL The waste containers are designed for proper disposal of used needles. Containers are environmentally safe. When burned properly at a waste disposal facility, containers emit only carbon dioxide and water. BEST MANAGEMENT PRACTICE (BMP) Collect sharps in a red or yellow puncture resistant container with a lid that cannot be removed. The sharps container should be properly labelled with biohazard symbol. Once container is full, the biomedical waste should be disposed by contacting a certified biomedical waste carrier. Never throw sharps in a regular garbage bag and never place other biomedical wastes materials 110
RAJARAM NAIK, SURESHCHANDRA B., SRINIDHI HEGDE, AFTAB DAMDA, MEETA MALIK MERCURY CONTAINING WASTES ELEMENTAL MERCURY WASTE MANAGEMENT OPTIONS BEST MANAGEMENT PRACTICE (BMP) Store unused elemental mercury in a tightly sealed, break resistant container and label those container properly; Hazardous Waste: Elemental Mercury Contact a certified waste carrier for recycling or disposal. Most cities in India have certified waste collectors approved by the pollution board of India Use a mercury spill kit if you have a spill of elemental mercury. MERCURY SPILL KIT React unused elemental mercury with silver alloy to form scrap amalgam. Never transport elemental mercury yourself nor place it in the garbage. Elemental mercury should never be washed down the drain. It is often simpler and more cost effective to reduce or eliminate the generation of waste at the source so that the liability is never created. MERCURY CONTAINING WASTES SCRAP AMALGAM WASTE MANAGEMENT OPTIONS Some of the metals in amalgam are hazardous to the environment. The provincial regulations in most nations prohibit the release of these wastes (mercury and silver) into the regular waste stream and further restrictions apply to these metals in the sewer systems. It is important for dentists to minimize the release of these wastes from the dental office. Scrap Amalgam Best Management Practice (BMP) Use a Sponge type MercontainerTM to store the scrap amalgam. Empty amalgam capsules are non-hazardous and can be disposed in the garbage. Use an ISO 11143 compliant amalgam separator on the suction lines to remove over 95% of the contact amalgam prior to entering the sewer system. Use disposable suction traps on your dental units and change them weekly. Use gloves, mask, and glasses when cleaning the suction traps. Place the used disposable trap into a properly labelled container of MerconvapTM solution for proper disposal. Once full, contact a certified waste carrier for recycling or disposal. GOOD MANAGEMENT PRACTICE (GMP) Use a properly labelled container with mercury vapour suppressant such as fixer or MerconvapTM solution to submerse the amalgam particles. Make sure the container is labelled Hazardous Waste: Scrap Amalgam. Mix only as much amalgam as is immediately required using premeasured capsules. Manually remove large pieces of amalgam which are produced when removing old fillings and place them in a contact amalgam container.consider using amalgam substitutes in cases where they are appropriate 111
BEST MANAGEMENT PRACTICES FOR HAZARDOUS DENTAL WASTE DISPOSAL (clinically equal or superior to amalgam), ethical and economically feasible. Use gloves, mask, and glasses when removing the non-disposable traps from the suction line. AMALGAM SEPARATION The basic types of amalgam separation technologies are the sedimentation units which reduce the speed of the downflow of water with baffles or tanks to allow amalgam particles to settle. Centrifuge units spin the water out to the sides of the unit. These units offer good amalgam removal but cause some foaming with American vacuum systems. Ion Exchange units use polymers to capture small particles; these are often used in series with sedimentation units. Other wastewater treatment technologies such as electrolysis and chemical additions have been adapted for dental applications. Personal Protective Equipment Remove all visible amalgam by tapping the trap into a MercontainerTM. Never dispose scrap amalgam in the garbage and never wash it down the drain. Do not place scrap amalgam in the sharps container and never rinse the traps and filters in the sink as amalgam particles will discharge into the sewer. Do not throw disposable traps that contain amalgam particles into the garbage Do not place extracted teeth with amalgam fillings in the regular garbage. It should be disposed of in the Scrap Amalgam container to avoid incineration Do not suction up unused particles of amalgam, instead place them in a mercury vapour suppressant container ISO Certified Amalgam Separator Safe and effective management of waste is not only a legal necessity but also a social responsibility. Lack of concern, motivation, awareness and cost factor are some of the problems faced in the proper hospital waste management. Proper surveys of waste management procedures in dental practices are needed. Clearly there is a need for education as to the hazards associated with improper waste 112
RAJARAM NAIK, SURESHCHANDRA B., SRINIDHI HEGDE, AFTAB DAMDA, MEETA MALIK disposal. Lack of apathy to the concept of waste management is a major stymie to the practice of waste disposal. An effective communication strategy is imperative keeping in view the low awareness level among different category of staff in the health care establishments regarding biomedical waste management. Hence, health care providers should always try to reduce the waste generation in day-to-day work in the clinic or at the hospital. References: 1. Thomas Barron. Mercury in our Environment. CDA Journal 2004;32(7)556-563. 2. Richard T. Kao, Scott Dault, Teresa Pichay Understanding the Mercury Reduction Issue: The Impact of Mercury on the Environment and Human Health. CDA Journal 2004;32(7)574-579. 3. Michael W. Davis. A Review of the ADA Mercury Hygiene recommendations. Dent Today 2003.22:86-91. 4. Thomas W. Clarkson,Laszlo Magos, Gary J. Myers. The Toxicology of Mercury-Current Exposures and Clinical Manifestations. N Engl J Med 2003;349:1731-1737. 5. ADA Council Of Scientific Affairs. Dental Mercury Hygiene recommendations. JADA 2003;134:1498-1499. 6. Mc Manus KR, Fan P L, et al. Purchasing installing and operating dental amalgam separators : Practical issues. J Am Dent Assoc. 2003 August ; 134(8) : 1054-65. 7. Leggat PA, Chowanadisai S, et al. Occupational hygiene practices of dentists in Southern Thailand. Int. Dent J. 2001 Feb; 51 (1) : 6-11. 8. Guidelines for the Management of biomedical Waste in Canada. February 1992. 113