Contents. 10 Appendix C - Waste classification table. 3 Waste policy. 4 Storage and collection. 5 Waste labelling. 3 Waste classification

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2 This guidance is tailored to general dental practice and ensures that dental healthcare waste is managed in accordance with the current waste regulations. It is based on the dental sector guide in HTM Safe Management of Healthcare Waste (March 2011) which was produced by the Department of Health in conjunction with the Environment Agency. This now mirrors the advice in HTM Appendix 1 Waste Disposal. Where dental practice activities take place in a hospital or community setting, local arrangements for the management of healthcare waste should be followed. Contents 3 Waste policy 3 Waste classification 3 Clinical waste 3 Sharps waste 3 Extracted teeth 3 Chemicals 4 Medicines 4 Dental amalgam 4 Gypsum waste 4 Electrical wastes 2 4 Storage and collection 5 Waste labelling 5 Consignee returns 5 Waste audits 6 Registration with the Environment Agency 6 Health and safety 6 Training 6 Appendix A - Use of extracted teeth 8 Appendix B - Amalgam seperators 10 Appendix C - Waste classification table

3 3 Duty of Care As healthcare waste producers, dentists have a duty of care to ensure all healthcare waste is managed and disposed of properly. The dental practice is solely responsible for ensuring its waste is: correctly segregated, stored safely and securely on premises; packaged appropriately for transport; described accurately and fully on the accompanying documentation when removed; transferred to an authorised person for transport to an authorised waste site; registered (where necessary) as a hazardous waste producer with necessary records and returns held at the premises. Waste policy Each dental practice should have in place a healthcare waste policy which identifies who is responsible for healthcare waste and how it should be managed. The policy should identify how the waste is classified, segregated, stored and handled along with the practice arrangements for collection and record keeping. Waste classification The waste table below outlines some key dental waste streams, including an explanation of each stream, what waste containers should be used, what can be placed in these containers, how waste should be classified and described, and advice on waste disposal. Clinical waste Orange bags should be used for soft clinical (infectious) wastes and are used to indicate that the waste is suitable for alternative treatment processes, rather than requiring incineration. Medicinally, chemically or amalgamcontaminated wastes must not be placed in the orange bag. The non-hazardous offensive waste stream should only be used for soft wastes from dentistry which are not contaminated with bodily fluids (for example, uncontaminated PPE and hygiene wastes from toilets). In the dental surgery, the full medical history of patients is not always known. In these circumstances, all waste contaminated with body fluids can be regarded as potentially infectious, including saliva which may contain traces of blood. This does not extend to uncontaminated items. Sharps waste Sharps are items that could cause cuts or puncture wounds, including needles, syringes with needles attached, broken glass ampoules, scalpels and other blades. Sharps waste should be collected in yellow lidded receptacles that require disposal by incineration. Extracted teeth Extracted teeth containing amalgam are hazardous waste and the presence of amalgam means that these teeth cannot be incinerated, so they must not be put into the sharps box. Instead, they should be collected and disposed of separately in a suitable container provided by the waste collection. Guidance on the use of extracted teeth for training or research purposes is in Appendix A company. Extracted teeth without amalgam should be disposed of via the dental sharps box. Chemicals The dental practice is likely to use a range of chemicals and photochemicals including disinfectants, hand gels, resins, reagents and diagnostic kits. The practice waste management contractor can advise on the safe disposal requirements for such materials, however, a number of key points to note include: Empty containers are likely to contain sufficient residue to remain hazardous chemical wastes unless rinsed. If these are to be rinsed and the water is discharged to the foul sewer via the sink, a trade effluent consent may be required. The dental practice should contact its local water company. Alcohol hand gels that do not contain siloxanes and whose safety data sheet does not prohibit discharge to the sewer, may be rinsed out and the packaging recycled or placed into the domestic waste stream. Chemicals should not be disposed of in the clinical waste stream. Waste radiographic fixer and developer solutions are classified as hazardous and should be collected by a suitably licensed company or waste facility for material recovery. If recovery is not appropriate, fixer and developer solution should be incinerated at suitably licensed or permitted facilities. Some chemicals may react to produce fire or toxic gases. These incompatible chemicals should be disposed of and stored separately. Flammable, corrosive and oxidising chemicals are of particular concern in healthcare.

4 Medicines The dental practice will use and dispose of a range of medicines including anaesthetics, antibiotics and painkillers. It is common practice for the medicinal containers used to charge syringes to be disposed of in the sharps container along with the syringe. The dental practice must, however, ensure that the waste description and classification identifies this. A blue-lidded yellow container represents the new recommended national colour code for non-hazardous waste medicines. It was previously a yellow-lidded container as specified in Health Technical Memorandum 01-05, and whilst a blue lid is recommended, it is not compulsory. If the dental practice returns medicines to a local pharmacy, the same legal requirements apply as transferring them to a waste contractor. The dental practice must discharge its duty of care and in particular must use waste documentation and keep appropriate records. If the dental practice (or the pharmacy) is inspected by a regulator, it should expect to be asked to produce the required documents and records. Dental amalgam Dental amalgam is classified as hazardous waste and includes amalgam in any form and materials contaminated with amalgam. Amalgam waste should be collected by suitable licensed or permitted waste management facilities where the waste undergoes a mercury recovery process prior to final disposal. Amalgam capsules are also classified as a hazardous waste. Dental practices which place or remove amalgam fillings must install amalgam separators and ensure the amalgam collected is disposed of as hazardous waste. Separators should meet the British Standard Dental equipment amalgam separators (BS ISO EN 11143:2000). Further information on the installation of amalgam separators in dental practices is in Appendix B. Gypsum waste Most dental study models will contain gypsum which, when land-filled, can produce hydrogen sulphide gas. As such they can no longer be disposed of in normal commercial/trade waste (or as clinical waste). Local authority waste departments should be able to identify appropriate local facilities where this waste can be taken to be either recycled or appropriately disposed of. Waste companies may also be able to offer an appropriate collection service. Electrical wastes Many electrical wastes including refrigerators, freezers, fluorescent tubes, televisions, cathode-ray tube and flat screen computer monitors, and lead acid or nickel-cadmium batteries are hazardous and must therefore be consigned from the dental practice. The local civic amenity site is unlikely to be authorised to accept commercial electronic waste but if it is, ensure a consignment note is used. When new equipment is purchased there is an opportunity to make arrangements with the supplier to remove the old one (suppliers may not mention this so and the practice may need to be proactive). It may also be possible to call upon an equipment producer who is a member of a responsible producer compliance scheme (PCS) to take-back and treat the old equipment. The Environment Agency gives details of PCS membership. Storage and collection The collection of healthcare waste should occur at regular intervals to reduce its build up in the premises. If soft clinical waste is stored outside the practice for collection, it must be secure and not accessible to outside interference. Waste produced in domestic households during home visits may be brought back to the dental practice for collection. No waste documentation is required and there is an exemption from the requirement for an environmental permit for temporary storage by the producer. Hazardous waste cannot move between practices without the use of consignment notes, and the receiving practice registering with the Environment Agency as a hazardous waste consignee and meeting the considerable legal obligations. Radiographic developer and fixer solutions, dental amalgam and waste containing cytostatic and cytotoxic drugs will have collection containers supplied by the licensed waste collection companies. White rigid containers with a mercury suppressant are preferred for dental amalgam. Waste radiographic developer and fixer solution should be stored in leak proof containers. 4

5 Waste labelling All hazardous waste and medicinal waste containers must be individually and clearly labelled to identify both the nature of the waste present (including classification codes where possible); and the details of the dental practice. Documentation The following information summarises Department of Health and Environment Agency guidance: Hazardous waste consignment notes Before the waste is removed from premises on the collection route, the practice (as producers) must complete the notification details and the description of the waste and then sign the note. Whilst it is the practice s responsibility to fill in these sections, the carrier may obtain these details from you and complete them on your behalf. This will enable the carrier to take appropriate measures to ensure wastes are packaged, labelled and handled correctly, and that the consignee (the person who receives the waste for final disposal) is able to take it. In each case the practice must ensure that the carrier has completed the note correctly (notification and waste details) and that the carrier is registered to collect waste. The practice is also declaring that the waste is packaged and labelled correctly. If you are aware of any particular handling issues with the waste you should inform the carrier about them. Usually the carrier will be collecting more than one consignment of waste in a journey from different premises. If this is the case then a Multiple Collection consignment note will be used. After the carrier has signed the annex he needs to give the practice a copy of the annex and a copy of the Multiple Collection consignment note for them to keep for three years. European Waste Catalogue (EWC) codes must be included on the waste transfer note and the hazardous waste consignment note. The codes relevant to dental waste are shown below. Hazardous Waste Consignment Notes also require the addition of a SIC (Standard Industrial Classification) code. For dental practices the SIC code is: (dental practice activities). Remember: Hazardous waste collection companies are entitled to pass on a consignment note fee each time hazardous waste is collected. Consignee returns The waste collection company is also required to send the practice a return each quarter. This return is a record of what has happened to your waste and must be placed with your other waste records. The return may be provided by a consignee return form or a copy of the consignee s copy of each consignment note together with a description (or confirmation) of the method of disposal or recovery applied to the waste. These returns contain the information on the quantity, nature, origin, destination, frequency of collection, mode of transport, waste carrier and the disposal or recovery operation applied, to the waste received, that are required by the Regulations. Return forms or copies of consignment notes should be sent to the practice within one month of the end of the quarter during which the waste was accepted. If the practice does not have these returns your records will be incomplete. Where your waste contractor has not provided you with returns you should request them in writing from the waste contractor. If this is unsuccessful you should consider making alternative arrangements for your waste until your waste contractor complies with the law, and pass their details to the Environment Agency. Waste audits Waste segregation and procedures should be audited every two years for the following reasons: 1. This enables the dental practice to accurately describe and classify its waste to complete its waste documentation and discharge its duty of care. 2. The waste disposer may be required by their permit to obtain an audit from the dental practice before they can accept the waste (a pre-acceptance audit). 3. This enables the dental practice to monitor its waste practices, identify any problems and as a result enables it to fix them. An example BDA preacceptance waste audit is available in BDA Expert. 5

6 Registration with the Environment Agency Dental practices are exempt from notifying the agency as long as the total amount of hazardous waste produced in any twelve-month period is less than 500kg. There is no limit on the number of consignments that can be made from the premises under the registration exemption. Where a practice owner initially considers that less than 500kg of hazardous waste (such as developer and fixer solution, dental amalgam, etc) will be produced from the practice but later anticipates that this limit will be exceeded, the practice owner must notified the Agency before the limit is exceeded. Registration ( 18 per year) can be made through the Environment Agency website. Note: Non-healthcare related hazardous waste also needs to be taken into consideration when deciding if the 500kg weight threshold is exceeded. Non healthcare hazardous waste includes, but is not limited to, televisions, computer monitors and fluorescent tubes. Health and safety Arrangements for managing healthcare waste needs to be part of the overall health and safety management system for the practice. This is largely based on the assessment of risks and the information below should be considered alongside the practice risk assessment. To comply with the regulations practitioners must, among other things: assess the risks to employees and others from healthcare waste make arrangements for renewing the assessment as and when necessary aim to eliminate or prevent these risks, if this is not possible to adequately control the risks provide suitable and sufficient information, instruction and training for employees about the identified risk and controls offer immunisation where appropriate. Protective clothing (gloves) should be used for the handling and movement of clinical and hazardous waste when deemed necessary by the practice COSHH assessment and if spillages occur. All employees that handle clinical waste should be vaccinated against hepatitis B. Training Training needs vary depending on the job and on the individual. All dental staff involved in handling healthcare waste should receive training, information and instruction in: the risks associated with healthcare waste, its segregation, handling, storage and collection personal hygiene any procedures which apply to their particular type of work procedures for dealing with spillages and accidents and; the appropriate use of protective clothing. Appendix A - Use of extracted teeth The Human Tissue Act 2004 regulates the taking, storage and use of human tissue which include extracted teeth. The parts of the Act relevant to the use of extracted teeth apply to England, Wales and Northern Ireland. Further information is available from the Department of Health: Patients should be offered the choice of whether they retain the tooth or it is disposed of by the dentist as clinical waste. If the dentist wishes to retain and store a tooth or teeth from a living person, and/or give it to another organisation for one of the regulated purposes specified under the Act, the consent of the patient is required. The person storing and/or using the tooth/ teeth for research purposes must be licensed by the Human Tissue Authority. The general regulated purposes for individuals which require consent for the taking and storage of relevant material (that is material containing human cells) are listed in Part I of the Schedule of the Act and are: anatomical examination obtaining scientific or medical information about a living or deceased person which may be relevant to any other person (including a future person) determining the cause of death establishing after the person s death the efficacy of any drug or other treatment administered public display research in connection with disorders, or the functioning, of the human body transplantation. 6

7 7 Consent is not required for storage and use of tissue for the following purposes listed in Part 2 of the Schedule of the Act: clinical audit education and training relating to human health performance assessment public health monitoring quality assurance. If the relevant material was removed at post mortem, consent would be required for these Part 2 purposes which would not have been required if the material was removed from a living person. A person s agreement or refusal to consent to donation; storage or use of tissue for purposes under the Act must not affect the investigation or treatment that s/he receives. When consent is necessary for the regulated purposes under the Act, the general legal principles that apply to consent for treatment and examination apply equally to consent for storage and use of tissue. Donating teeth for research purposes Patients are expected to consent to the taking and storing of their extracted teeth for the purposes of health-related research. However, there are circumstances where consent may not be required although it is recommended, these are when the research organisation is licensed to store the material and the research has ethical approval. Such research must comply with the following conditions: it has been ethically approved (currently that is approval by the relevant Local Research Ethics Committee) the research is being undertaken in circumstances where the identity of the individual donating the tissue is not known by those conducting the research (that is, it is anonymised). Residual tissue is often an important source of material for research and it is therefore advisable to obtain appropriate consent prior to the treatment if the material could be used in this way. For living individuals, under the Act teeth can still be used for education and training purposes (which are not for obtaining scientific or medical information), without the individual storing the teeth being licensed or without having obtained consent. However, regardless of the Act, the extraction of teeth requires consent to be obtained which is governed by the general legal principles applying to consent for treatment and examination. With consent, extracted teeth can be taken, retained and used for public display provided that the person storing the teeth is licensed. For an adult before death, or parent consenting for a child that has died, this consent must be in writing. Licensing Individuals and organisations that store and use tissue from a living person for a regulated purpose are required to be licensed by the Human Tissue Authority. Disposal The Act allows residual tissue samples left over following a diagnostic or therapeutic intervention or research to be disposed of lawfully. It also states that material no longer used or stored for use, for any regulated purpose can be dealt with as waste. It is recommended that a time-limit should be considered for the storage of organs and tissue. Codes of practice The Human Tissue Authority issued Codes of Practice to cover its areas of operation. This includes Codes covering consent and the removal, storage and use of human tissue. Licensed organisations are required to comply with the Codes of Practice. Health and safety issues If teeth are to be disposed of: extracted teeth are clinical waste but also sharps, so should be disposed of via sharps bin if the tooth contains amalgam it becomes more tricky because amalgam must not be incinerated so these teeth should be segregated and disposed of with waste amalgam as hazardous waste. If the tooth/teeth are to be passed on to a third party: the tooth should be disinfected before passing onto a third party if the tooth contains no amalgam, it can be sterilised in the autoclave but if it contains an amalgam it can only be disinfected as an autoclave may vaporise the mercury which becomes a problem under COSHH. If teeth are retained by the patient they do not need to be disinfected/sterilised.

8 Appendix B Amalgam separators Dental amalgam still remains the most popular form of filling material used by the dental profession and usually consists of 50% mercury by weight. Although there has been a reduction in the amount of dental amalgam being used, due to a fall in the incidence of dental caries throughout the UK, waste dental amalgam, through its mercury content, still remains an environmental problem. Legal Requirements The Hazardous Waste Regulations came into force 2005 in England and Wales, with similar regulations existing in Scotland and Northern Ireland. This means that all waste dental amalgam is now classified as hazardous waste, and as such, discharge to sewer is not allowed. To comply with the regulations dental practices (both existing and new) will have to fit amalgam separators and ensure the amalgam collected is disposed of in accordance with the regulations. These separators should meet the requirements of the British Standard Dental Equipment Amalgam Separators (BS ISO EN 11143:2000). Existing simple filters and gause material will not be sufficient to comply with the legislation. This was confirmed by DEFRA in its guidance to the profession in December 2005 Method of Separation Amalgam particles can range from 0.45 micrometers to larger than 3 mm. To remove these various sized particles from waste discharge, amalgam separators can use a range of techniques, alone or in combination, which include sedimentation, centrifugation, ionexchange or filtration. Sedimentation based separators have baffles or tanks that reduce the speed of the waste water flow allowing amalgam particles to settle out of the waste Centrifuge based units spin waste water and draw the amalgam particles to the sides of the unit Ion-exchange units take advantage of the tendencies of certain chemicals to bind with dissolved mercury causing the particles to separate from the solution and rest at the bottom of the separator. Filtration is often used in combination. Some separators, for example, use sedimentation followed by filtration and ion exchange, with the aim of removing smaller amalgam particles not removed by sedimentation as well as dissolved mercury particles. Installation and positioning of units There are a large variety of amalgam separators currently on the market. These can either be retro fitted to the existing suction equipment in each surgery or at the central suction unit if this exists. It might be possible to install the unit at the outflow pipes of the premises, but only if all waste routes containing waste amalgam discharged through the same waste pipeline. Choosing where to install the separator is important and affects the size and cost of the unit required. The time needed for installation will vary between the models and may put a surgery out of action for several hours depending on its layout. You should be aware of what is involved before deciding which separator to purchase. Some dental practices will have easily accessible waste piping that would make fitting one separator to the entire premises more practical (and possibly cheaper). Other practices may require separators for individual surgeries. Waste water from other sources (such as washer/disinfectors) may affect the workings of the unit and should be considered before installation, along with the ability of the separator to handle the amount of water being passed through it. Servicing, maintenance and retrieving amalgam waste may also take time. A single separator that serves the whole practice may require more frequent maintenance and amalgam retrieval and will add to the overall total cost of the separator, yet this could be balanced by less surgery down time depending on its location. Do explore the options and make estimates of the time needed for installation and routine servicing as well as the long-term costs involved. 8

9 9 Information from suppliers With the number of separators available, and the different installation, maintenance and collection methods to choose from, it is important to get as much information as possible from the manufacturers or suppliers to allow you to estimate the total cost to the practice. The British Standard asks manufacturers and suppliers to provide certain information and instructions along with the amalgam separator including: 1. Name, trademark and address of manufacturer or distributor 2. Specifications and instructions for installing and connecting the amalgam separator 3. Maximum water flow rate for the separator 4. Description and procedure for emptying the collecting device 5. Description of the appropriate interval for changing of the collecting container, if applicable 6. Whether the alarm or warning signal is installed in the surgery if the unit is installed distant from the practice. 7. Description of the procedure for disposal of the separated substances. It is also worth checking whether the practice will need to have a separate collection of waste amalgam that is mixed in the surgery or whether this can be collected at the same time as the waste amalgam is retrieved from the separator (saving the cost of additional collections). Amalgam Separator Checklist When deciding which separator to purchase, consider the following: 1. Does the separator meet the requirements of the current British Standard 2. Can the separator be easily fitted to existing equipment? 3. Is it possible to have a single unit serving the whole practice or several surgeries or are individual units needed? What are the comparative costs (including installation and ongoing maintenance)? 4. How long will the separator(s) take to install? Is the cost of installation included in the purchase price? 5. How will you know if the separator is full? 6. How much does routine maintenance / collection cost? 7. How long does this usually take? 8. Will patients still be able to be treated when this is happening? 9. What is the length of contract on offer? Is there a minimum period? What are the terms for terminating the contract? Enforcement The Environment Agency will have the power to inspect all premises where waste classified as hazardous is being produced, including dental practices, to ensure the requirements of the new regulations are being complied with. Failure to install amalgam separators could ultimately result in prosecution by the agency. Practices should, therefore, make arrangements for the installation of amalgam separators before the date of commencement of the regulations. A list of companies who supply amalgam separators can be found through the British Dental Trade Association.

10 Appendix C - Waste classification table 10

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