2. Putting Into Place the BMPs for Amalgam Waste
Frederick Eichmiller, DDS
VP & Science Officer
Delta Dental of Wisconsin

3. Amalgam
Material
A mixture of elemental mercury with powdered silver-tin-copper alloy
Mercury combines with silver and tin to form stable strong intermetallic compounds
Powder (~50%) Liquid (~50%)
Silver 63% Mercury 100%
Tin 23%
Copper 13%
Zinc <1%
Ag3Sn + Hg  Ag2Hg3 + Sn7-8 Hg

4. The Amalgam Revolution
Early attempts with lead, tin and bismuth
The “Amalgam War” of 1850
Dentists manufacturing amalgam
G.V. Black formula (1890s)
The first amalgam standard (1920)
Modern alloys (1960s)

6. Lost “most used” status between 1998 & 1999
Utilization in North America is dropping at a constant rate
Some European are countries eliminating use
Global demand remains fairly constant

7. Alternatives

8. Amalgam Most cost effective from cost-service standpoint
Still only “underwater dentistry” material
Still frequently the Tx of choice in some situations

9. Human Toxicity What kind of Hg is it? What’s the route of exposure?
What’s the dose?

12. Mercury: Man’s Deadly Servant National Geographic October 1972
J. Osborne

13. Biological Activity 70 trace elements in human body
35 have no biological activity Mercury has no biological activity
Carcinogen: no positive human results
Teratogens: highly positive, numerous systems
J. Osborne

14. Liquid Mercury Very low absorption on skin Less than 0.01% absorption
J. Osborne

15. Liquid Mercury (continued)
No toxic effect when swallowed
Less than 0.01% absorption
Miller-Abbott (bowel obstruction) tube breaks 2% to 3%
Pre-1900s drink a pound of Hg for constipation
7 lbs. Hg ingested (1/2 pint) took 10 days to clear
J. Osborne

16. Liquid Mercury (continued)
Bizarre forms
Inject subcutaneously, intramuscular and intravenously
Cause local inflammation, abscess and gangrene
Patient does not see doctor for years
Rarely causes severe mercury toxicity

17. Inorganic Mercury HgCl2 mercuric chloride (corrosive sublime)
Chemical catalyst, preservative, treatment for syphilis
Hg2Cl2 mercurous chloride (calomel)
Diuretic and laxative, electrodes
HgO mercuric oxide (montroydite)
Batteries
HgS mercuric sulfate (cinnabar)
Red tattoo color, native ore of Hg
Hg(ONC)2 mercury fulminate
Contact detonators
J. Osborne

18. Organic Mercury Alkyl Aryl Phenyl methyl - food chain, shellfish,
ethyl - preservative
Aryl
aromatic series
anti-fungal on seeds
Phenyl
prevent mildew
J. Osborne

19. Organic Mercury Methyl mercury: Very toxic 90-95% absorbed in gut
half-life days
Hg enters waterway
Methylation by microorganisms
Hg concentrated as it moves up food chain (tuna, shark, and swordfish)
J. Osborne

20. Organic Mercury Ethyl mercury, preservative Thimerosal (mercurochrome)
controls microbial growth % used in:
Soaps
Shaving cream
Hyper allergic cosmetics
Ear flush
Multidose vaccines
Gamma-globulin shots
Ophthalmic solutions
Shampoos
Nasal sprays
J. Osborne

21. Organic Mercury Aryl Aromatic series anti-fungal for seeds
Highly toxic
90-95% absorption in gut
Widely used in agriculture
J. Osborne

22. Mercury Vapor 80% absorbed in lung Significant toxicity when inhaled
Accounts for most occupational and home exposures
Acute toxicity is rare, but can occur
Large dose causes acute pneumonitis, renal failure, seizures and neurological dysfunction
J. Osborne

23. Mercury Vapor
Sun light →
UV light ←
J. Osborne

24. Hg Sources
50% of the mercury released to the environment comes from human activity
Of that amount:
53% is emitted from combustion of fuels for energy production and
34% is from the combustion of waste
13% from all other sources, including manufacturers and consumers
Dentistry contributes less than one percent
EPA Data

25. 2001 Hg Use in Products Electric Other Lighting 7% 9% Electronic
Measuring
and Control
Devices
28%
Dental
14%
Other 7%
Electronic
Switches
42%
Electric
Lighting 9%
EPA Estimates

26. Common Mercury-Added Products

27. Hg in Products Hg content in common products: Toothpaste 3.8 ppb
Deodorant ppb
Soap ppb
Laundry detergent 2.4 ppb
Kool-Aid 6 ppb
Mountain Dew ppb
Hampton Roads Sanitation District

28. USGS/ICE CORES

29. Dental Use of Mercury
No organic or inorganic mercury is used in dentistry or in dental amalgam
Restorations in 1999 required approximately 35 tons of elemental Hg in the U.S.
The use of amalgam and mercury in dentistry continues to drop at a fairly constant rate (58% from )

30. (Publicly 0wned Treatment Plants)
The Dental Hg Trail
Chairside traps
and vacuum filters
(78% efficient)
Amalgam placements
and replacements
6.5 ton Hg
29.7 ton Hg
Sewers & POTWs
(Publicly 0wned Treatment Plants)
VanDeven JA & McGinnis SL Water, Air, and Soil Pollution
(2005) 164: 349–366

31. The Dental Hg Trail Hg emissions 0.1 tons Incinerated biosolids
1.0 tons Hg
Hg emissions
0.1 tons
Sewers & POTWs
POTW effluent
0.3 Tons Hg
Grit solids
1.6 tons Hg
6.5 tons Hg
Total Bioavailable
Up to 0.4 tons Hg
Beneficial use biosolids
3.6 tons Hg
VanDeven JA & McGinnis SL Water, Air, and Soil Pollution
(2005) 164: 349–366

32. So what’s dentistry’s relative contribution?
Tons/Yr
Municipal Waste
Combustors
Industrial Boilers
Hazardous
Waste
Combustors
Chlor-alkali
Plants
Portland Cement
Kilns
Geothermal
Power
Dental
Coal Utilities

33. Various Cities’ Estimates of Mercury Loads (% of Total System Loads) Coming From Dental Facilities76 80 60 34 40 26 13 14 11 20 9
Boston
Seattle
S.F.
Minn/St Paul
Cleveland
Duluth
Palo Alto

34. Typical Mercury Influent Loadings to a POTW (Metro Boston)
Infiltration
33%
Dental Offices
13%
Water Supply
<1%
Corrosion
Septage
DITP Recycle
Stream 7%
Residential Sewage
Inflow
11%
Unknown Commercial
20%
Permitted Industries 3%

35. Why is Mercury an Issue for Municipal Sewer Systems?
Plant performance and environmental conditions at outfalls closely scrutinized
Many POTWs are committed to beneficial re-use of biosolids as fertilizer and soil amendment
Cities operating combined sewers facing new restrictions on storm water flows

36. Why is Mercury an Issue for Municipal Sewer Systems?
Fish consumption advisories in 50 states
Discharge limits are being lowered nationwide
Mercury “Virtual Elimination Strategies” are gaining attention in NE, Great Lakes, other locations

37. The Regulatory Process
EPA’s maximum mercury allowed in surface water is µg /L of mercury per liter for states located along the Great Lakes and 0.05 µg /L for other states.
(µg/L = parts per billion)
States may use more stringent limits than EPA regulations.

38. Municipal Wastewater Treatment Facilities’ and Dentistry
Municipal POTWs are receiving more stringent mercury limits for their discharge
This requires them to begin to look “upstream” for additional sources of mercury
Dental offices have been identified by many cities as a significant mercury source to their systems
NACWA Position: “Pollution prevention efforts targeting sources of mercury should focus on dental offices and medical facilities (hospitals)”

39. They have a problem and they need our help!
The Unfortunate Facts
While our overall contribution to bioavailable Hg is very small, our contribution to an individual wastewater treatment facility averages approximately 40%.
Treatment facilities have a growing problem meeting their stricter discharge requirements.
They have a problem and they need our help!

40. The Solution to Pollution is Not Dilution

41. What about Mercury in Amalgam?
“While we recognize that dental amalgam is a safe material for filling cavities, its waste should be handled properly, recovered and recycled just as we do with other waste products.”
Dr. J. Bramson, Executive Director, ADA
July 2002 Press Release

42. So what can your office do today?

43. ADA Recommended Best Management Practices (“BMPs”) for Dentists

44. What are the BMPs? Use pre-capsulated alloys Recycle used capsules
Salvage, store and recycle amalgam
Recycle extracted teeth with amalgam restorations (following disinfection)
Use disposable chair side traps to retain amalgam; they can be recycled
Install and use amalgam separators

45. What are the BMPS? (continued)
Clean or replace screens, traps and filters regularly
Store amalgam wastes in separate airtight, labeled containers
Recycle all amalgam wastes through an amalgam recycler (including used capsules)
Use non oxidizing vacuum line cleaners

46. BMP Video

47. Practices to Avoid Never use bulk mercury for amalgams
Never pour bulk elemental mercury waste in the garbage, red bag or down the drain
Never place amalgam waste of any kind (including extracted teeth with amalgams) in the biohazard (red) bag, the trash or the sharps container

48. More Practices to Avoid
Never rinse traps, filters, or screens over or down the drain, or empty into a waste basket
Never disinfect teeth or any item containing amalgam with any method that uses heat

49. More Practices to Avoid
Never decant liquid in which amalgam has been stored down the drain
Never rinse tools used to place or carve amalgam over the drain
Never clean spills of elemental mercury with a vacuum cleaner

50. Proper Use/Maintenance of Existing Traps is an Important Amalgam Capture Mechanism

51. ADA Recommended BMPs for Dentists
Use non oxidizing agents or cleansers when flushing and cleaning dental suction systems

53. In-Office Separators
Sedimentation
Filtration
Ion Exchange

54. Sedimentation
From suction pump
To sewer
Scrap

55. Sedimentation + Filtration
From suction pump
To filter
Scrap
To sewer
Filter canister

56. Sedimentation + Filtration + Ion Exchange
From suction pump
To filter
Scrap
To sewer
Filter canister
Ion column

57. The Current ISO Test
Run a 10 g sample of amalgam powder through the separator with 1 liter of water
Capture 95% of the total mass of amalgam powder
Repeat with a system that is full

58. Separator Results Name Company Method Cost Empty / Full
Amalgam Collector
R&D Services
Sed
$350
99.9 / 99.9 %
Asdex
Avprox, Inc.
Filtr
$215
99.1 / 99.4 %
BullfroHg
DRNA Technologies
Sed/Filt
$100/mo
99.9 / 99.4 %
Durr 7800
Air Techniques
Centrifug
$4,000
98.1 / 97.7%
Eco II
Metasys
$29/mo
98.2 / 97.5 %
Hg 5
Solmetex
Sd/Fl/IonExch
$500
99.4 / 99.3 %
Hg 10
$6,000
99.9 / NT %
MRU
$150/mo
MSS 2000
Max. Separation Syst.
$3,000
99.7 / 98.9%
Rasch
AB Dental Trends
$2,730
RME 2000
Rebec
$1,895
99.7 / 99.7 %
Fan et al. JADA 2002;133:

59. Separators come in many different shapes and sizes; one size does not fit all!

60. Asdex Amalgam Separation System
Mfr
Installation Location
Features
American Dental Accessories
$229/unit
$79/filter
Chairside (recommended)
One unit per chair (recommended)
Monthly-quarterly replacement of filters (workload dependent)
Dimensions:
Diameter = 3”
Height = 9”

61. Installation Location
Solmetex Hg5 Unit
Mfr
Installation Location
Features
Solmetex Hg5
$695/unit
$150/filter cartridge
Between chair and vacuum pump
Handles up to 10 chairs
Operates using combination of physical settling and chemical filtration
Replace filter cartridge every 6 mos (or when full)
Hg10 for larger offices
Dimensions:
10” x 13” x 29”

62. Solmetex Hg5 High Volume Unit
Mfr
Installation Location
Features
Solmetex Hg5
$695/unit
$250/filter cartridge
20% discount available to dental society members
Between chair and vacuum pump
Designed for larger offices/higher wastewater flows
Replace filter cartridge every 6 mos (or when full)
Hg10 for larger offices
Dimensions:
18” x 22.5 x 28”

63. Installation Location
MRU
Mfr
Installation Location
Features
DRNA, Inc.
$1,800/year lease (includes service/replace-ment costs
Between chair and vacuum pump (can be at outlet)
120V AC (to pump treated effluent)
Capacity of 6-16 chairs (flow dependent)
Utilizes sedimentation, filtration, ion exchange
Dimensions:
12” x 16” x 24”

64. Installation Location
R&D Amalgam Collector
Mfr
Installation Location
Features
R&D Services
$495/unit (CH9, 12)
(can be emptied and reused)
Chairside (CH9 and12)
Central location, immediately upstream from vacuum pump (CH18)
Outlet height needs to be calibrated and adjusted to flow rate; decant as needed
Daily valve adjustments to remove treated effluent
Dimensions: 6”x6” x 9” (CH9)
6”x 6” x 12” (CH12)

65. Installation Location
Rasch 890
Mfr
Installation Location
Features
AB Dental Trends
$1190/unit
$596 per replacement unit
At outlet of vacuum system (wet system) or outlet of air/water separator (if already installed)
1 unit serves 12 chairs
Canister replacement 18 months
4 l/min flow rate
Upgrade canisters available for additional Treatment
Dimensions:
12.75”x 10.15” x 28.5”

66. Installation Location
ECOII
Mfr
Installation Location
Features
Pure Water Systems
$160+ $288 annual exchange and recycling
Between chair and vacuum system
1 unit/5 chairs
Annual Container exchange
Internal mercury recycling program
Utilizes specific GREEN & CLEAN M2 cleaner
Dimensions:
8.7” x 8.7” x 13.8”

67. Installation Location
REBEC Systems
Mfr
Installation Location
Features
Rebec
(4 units)
$ /unit
$ /settle tank
Between chair and vacuum system (not designed for chairside installation)
Units sized to handle different # of operatories; typical replacement recommended annually

68. Guardian Amalgam Collector
Mfr
Installation Location
Features
Air Techniques
$1,500-$3,225
After vacuum pump (drains by gravity
Replace collection container every 6 months
Dimensions:
6.3”x 10.5” x 7.5”

69. Installation Location
Amalgam Boss
Mfr
Installation Location
Features
Hygenitek
$695
Chairside or central location before vacuum pump
Replace unit annually
Sedimentation/ chemical filtration
Recycling program includes disposal costs
Dimensions: 12” x 20”

70. Practical Issues for Selection of Amalgam Separators
Cost
Effectiveness (Short and Long Term)
Maintenance, Reliability
Solids Handling and Disposal
Integrity of Vacuum Systems

71. Practical Issues for Selection of Amalgam Separators (contd)
Space and Utility Requirements
Dental Office/building Constraints
Regulatory Considerations
Ease of Maintenance and Replacement
Effect on Other Equipment

72. Typical Amalgam Separator Installation Locations

73. Separators Need to Be Maintained to Operate Effectively…
Amalgam, other waste buildup in air/water separation chamber

74. Who Should Install A Unit?
Licensed Plumber recommended
Licensed Electrician may be needed for systems utilizing pumps (depending upon application)
May be arranged by dental dealer (depending upon local code requirements, and lease requirements)

75. Space and Utility Requirements
Physical Dimensions of typical units
Height: 9-28”
Width/diameter:3-12”
Length 8-24”
Installation locations (relative to existing vacuum pump and air/water separators)
Electrical Power Requirements: Typically 110V if not utilizing vacuum system)

76. Dental Office Constraints
Basement vs. Office level installations
Access to Centralized plumbing Locations
Multi-chair installation requirements
Tenant/Landlord Issues

77. Other State/Local Regulatory Requirements to Check…
Plumbing Code requirements for separators
Amalgam Waste Handling Requirements
Approved Amalgam Separator list for your state, county or municipality

78. Amalgam Separator Buyer’s Checklist
Number of Operatories?
Amalgam restorations placed or removed per day?
Office operations (No. days/week)?
Dental practices/types located in your building?
Do you own or lease your space?
Would lease stipulations affect installation of a separator?
Source: Kevin R. McManus; P.L. Fan, Ph.D. Hanu Batchu, Purchasing, Installing and Operating Dental Amalgam Separators: Practical Issues, JADA

79. Amalgam Separator Buyer’s Checklist
What terms are included for utilities maintenance?
Do you operate wet/dry cuspidors?
Is sufficient space available to the air/water/separator drain line and sewer line connection?
Access to electrical power (voltage)
Size and material of existing sewer connection

80. Amalgam Separator Buyer’s Checklist
Do you operate wet or dry vacuum system?
Will any warranty be affected by third party installations?
Is the vacuum system dedicated to your office?
Location of the vacuum system?
Space available adjacent to vacuum system (height, length and width)?

81. Amalgam Separator Buyer’s Checklist
Recommended installation location
Maximum flow rate
Life-cycle cost†
In your group practice, who is responsible for:
Water/sewage/utilities?
Equipment servicing and maintenance?
Amalgam collection/recycling?

86. MAXIMIZING VOLUNTARY REDUCTIONS IN DENTAL AMALGAM MERCURY Reduction in Mercury Discharges EPA # E PI
                                                                           
Environmental Assistance Center
Marie Steinwachs, Director
Frederick Eichmiller, DDS
Co-Investigator

87. Goals
Determine whether significant reductions in mercury discharges from dental offices could be achieved through voluntary best management practices (BMPs)
Determine what effect BMPs have on mercury load to wastewater influent, effluent and biosolids
To assess the level of knowledge and compliance before and after BMP training

88. Partners Funding and support was provided by:
U.S. Environmental Protection Agency
American Dental Association Foundation
Springfield Public Works Department
Greater Springfield Dental Society
The University of Missouri Extension’s Office of Waste Management (now the Environmental Assistance Center)

89. Why Springfield?
Commitment of staff resources from the Springfield Public Works Department and the Greater Springfield Dental Society
Low existing level of BMP usage and few amalgam separators
Modern treatment facilities with little storm water loading and good access for sampling

90. Design
Influent and effluent samples collected at two treatment facilities using EPA method 1669
Total mercury determined by EPA method 1631 at Frontier Geosciences lab
Biosolid analysis done on monthly blended samples using EPA method 245.1
Pre-BMP sampling on wastewater done for 4 months, biosolid for two years
Intervention was a 1/2-day training seminar on BMPs followed by mailings and office visits

91. Intervention
½-day course provided on BMPs for dentists and office staff
Participants received a DVD, wall poster with best management practices, a brochure of other available resources, and articles including:
Dental mercury hygiene recommendations
ADA Guidelines on Amalgam Accumulations in Dental Office Plumbing
Summary of Recent Study of Dental Amalgam in Wastewater
Missouri Dept. of Natural Resources determination of status and options for various types of dental waste
List of amalgam recyclers

92. Questionnaire
A questionnaire was distributed to dentists by the Greater Springfield Dental Society and Environmental Assistance Center in February 2006
Collected baseline data on amalgam use and management practices. The questionnaire was a list of 34 questions adapted from a national survey of dental office practices conducted by the ADA.
A follow up survey was distributed to members of the Greater Springfield Dental Society (GSDS) in February 2007 to measure any changes in management practices after the education efforts as reported by area dentists.

93. Biosolid Results
No significant difference in biosolid levels after the April 2006 BMP training

94. Influent Results
No significant change after BMP training for NW plant with 3 dental offices

95. Influent Results
Highly significant reduction in loading to SW plant with approximately 90 dental offices

96. Effluent Results
No significant change in effluent loading after BMP training
for either treatment plant

97. Survey Results
35% of respondents (25) reported that they did not use dental amalgam.
Dental amalgam use decreased 5% from the year before.
A significant decrease (from 70% to 30% ) in improper disposal of capsules in regular waste was observed
16% increase in recycling of non-contact scrap, 41% increase in recycling of contact scrap
10% increase in the practice of placing non-contact scrap into medical waste containers, and nearly an 18% reported increase in placing contact scrap in medical waste

98. Traps and Filters
23% decrease in the practice of disposing of chairside trap contents with regular waste (42% to 19%)
21% increase in the recycling of trap contents (from 29% to 50%)
A decreases (from 39% to 21%) in the practice of placing filter contents in with regular office waste
Most of the respondents, 85% (up 20% from the year before) reported using vacuum pump filters
An increase (41%, up from 23%) in pump filter users who reported placing filter contents in a container with medical waste

99. Conclusions
The practice of BMPs in the area dental offices resulted in a measurable and significant reduction in mercury load to the influent wastewater of the treatment plants.
The practice of BMPs in the dental offices did not result in a measurable change in biosolid mercury levels.
The practice of BMPs in dental offices did not result in a measurable change in mercury load to effluent treatment water.
Better training needs to be provided to prevent amalgam waste from being mixed with medical waste for disposal

100. Line Cleaners
The following did not appear to mobilize Hg from amalgam particulate:
All-In-One
E-Vac
Evacuation Cleaner
EZ-Zyme
Gobble Plus
Green and Clean
MAXI-EVAC
ProE-Vac
Purevac
Sani-Treet Plus
Stay-Clean
Super-Dent
Turbo Vac Line Flush
VacuCleanse
VAC-U-EZ
Source: Naval Dental Research Institute

101. ADA’s Amalgam Waste Program
Label gray/silver container “Amalgam Waste for Recycling”
Store amalgam dry (not under fixer or other solutions)
Utilize USPS or parcel delivery service to ship container to qualified recycler
Keep written records of the date of the shipment, the approximate mass of waste being shipped, and the name and address of the recycler

102. ADA Amalgam in Plumbing Waste Initiative
ADA has prepared “Guidelines on Amalgam Accumulations in Dental Office Plumbing”
Includes guidance on new office design features
Pipe sample taken from MA dental office 2/03

103. ADA Guidelines are intended to apply to the following circumstances:
When plumbing work is being done in areas where waste may be likely to adhere;
When plumbing work is being done near areas where waste may accumulate and waste may be dislodged;
During major operatory renovations;
During demolition work;
Whenever the pipes are cleaned out or a dentist monitors adhered waste at the request of third parties.

104. ADA Amalgam in Plumbing Guidelines (New Offices)
Use of some basic design guidelines can help minimize collection and buildup of amalgam in office plumbing

105. Today, Dentists Have Better Information and More Choices
These BMPs will help ensure that dental offices properly handle and dispose of these wastes
The options and support for collecting and recycling amalgam waste have increased significantly over past few years

106. Thank you! And if All Else Fails…
Thank you!