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What is the proper protocol for disposing of amalgam?

Waste amalgam should be collected in the dental office for recycling by a licensed recycling facility. Amalgam (not free mercury) may be stored dry. Many hazardous waste haulers also will collect recyclable materials such as amalgam, mercury, lead foil, batteries, and fluorescent light bulbs. The American Dental Association published Mercury Hygiene guidelines in the November 2003 issue of the Journal of the American Dental Association, which is available online to ADA members.(1) As always, state and local laws or ordinances should be investigated before finalizing the procedure for amalgam disposal in your office. Your state dental association (2) may have resources to provide its members with regulatory guidance and assist in pollution prevention.

References: (1) ADA Council on Scientific Affairs. Mercury Hygiene guidelines JADA Vol. 134, Nov. 2003 1498-99

(2) ADA. List of constituent (state) dental societies of the ADA. Available at

What are the most current infection control recommendations for handling extracted specimen teeth in dental educational lab settings?

The Centers for Disease Control and Prevention (CDC) addressed this issue in Guidelines for Infection Control in Dental Health-Care Settings, 2003.(1) They state the following: "Extracted teeth that are being discarded are subject to the containerization and labeling provisions outlined by OSHA's bloodborne pathogens standard. OSHA considers extracted teeth to be potentially infectious material that should be disposed in medical waste containers. Extracted teeth sent to a dental laboratory for shade or size comparisons should be cleaned, surface-disinfected with an EPA-registered hospital disinfectant with intermediate-level activity (i.e., tuberculocidal claim), and transported in a manner consistent with OSHA regulations. However, extracted teeth can be returned to patients on request, at which time provisions of the standard no longer apply. Extracted teeth containing dental amalgam should not be placed in a medical waste container that uses incineration for final disposal. Commercial metal-recycling companies also might accept extracted teeth with metal restorations, including amalgam. State and local regulations should be consulted regarding disposal of the amalgam."

Additionally, extracted teeth should be cleaned and then decontaminated with a suitable disinfecting or preserving agent.(1,2) Extracted teeth without amalgam fillings may be autoclaved. (Teeth containing amalgam should never be heat sterilized because the high temperatures of the sterilization cycle can release mercury vapor.)(2,3). Extracted teeth may be given to the patient or may be used in an educational setting once proper decontamination procedures have been conducted.

References: 1) CDC. Guidelines for Infection Control in Dental Health-Care Settings --- 2003. December 19, 2003 MMWR 52(RR17);1-61

2) Tate WH, White RR. Disinfection of human teeth for educational purposes. J Dent Educ 1991;54(5):583-5.

3) Cuny E, Carpenter W. Extracted teeth: decontamination, disposal and use. CDA J 1997;25(11):801-4.

What is the proper biohazard disposal protocol for gauze?

First and foremost, all federal, state, and local regulations, laws, and standards apply. In addition to complying with OSHA Standards all EPA standards must be met. OSAP does not maintain state regulations, laws, or requirements, therefore, you should also contact your state and local EPA officials (Solid waste management division) for all applicable requirements for waste disposal in your area.

We would like to refer you directly to the Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental Healthcare Settings. The guidelines state the following:

Non-regulated and Regulated Medical Waste

Studies have compared microbial load and diversity of microorganisms in residential waste with waste from multiple health-care settings. General waste from hospitals or other health-care facilities (e.g., dental practices or clinical/research laboratories) is no more infective than residential waste. The majority of soiled items in dental offices are general medical waste and thus can be disposed of with ordinary waste. Examples include used gloves, masks, gowns, lightly soiled gauze or cotton rolls, and environmental barriers (e.g., plastic sheets or bags) used to cover equipment during treatment. (1)

Although any item that has had contact with blood, exudates, or secretions might be infective, treating all such waste as infective is neither necessary nor practical. Infectious waste that carries a substantial risk of causing infection during handling and disposal is regulated medical waste. A complete definition of regulated waste is included in OSHA's bloodborne pathogens standard. (1)

Regulated medical waste is only a limited subset of waste: 9%-15% of total waste in hospitals and 1%-2% of total waste in dental offices. Regulated medical waste requires special storage, handling, neutralization, and disposal and is covered by federal, state, and local rules and regulations. (1)

Examples of regulated waste found in dental-practice settings are solid waste soaked or saturated with blood or saliva (e.g., gauze saturated with blood after surgery), extracted teeth, surgically removed hard and soft tissues, and contaminated sharp items (e.g., needles, scalpel blades, and wires). (1)

Regulated medical waste requires careful containment for treatment or disposal. A single leak-resistant biohazard bag is usually adequate for containment of non-sharp regulated medical waste, provided the bag is sturdy and the waste can be discarded without contaminating the bag's exterior. Exterior contamination or puncturing of the bag requires placement in a second biohazard bag. All bags should be securely closed for disposal. Puncture-resistant containers with a biohazard label, located at the point of use (i.e., sharps containers), are used as containment for scalpel blades, needles, syringes, and unused sterile sharps. (1)

Dental health-care facilities should dispose of medical waste regularly to avoid accumulation. Any facility generating regulated medical waste should have a plan for its management that complies with federal, state, and local regulations to ensure health and environmental safety. (1)

Discharging Blood or Other Body Fluids to Sanitary Sewers or Septic Tanks

All containers with blood or saliva (e.g., suctioned fluids) can be inactivated in accordance with state-approved treatment technologies, or the contents can be carefully poured down a utility sink, drain, or toilet. Appropriate PPE (e.g., gloves, gown, mask, and protective eyewear) should be worn when performing this task. No evidence exists that bloodborne diseases have been transmitted from contact with raw or treated sewage. Multiple bloodborne pathogens, particularly viruses, are not stable in the environment for long periods, and the discharge of limited quantities of blood and other body fluids into the sanitary sewer is considered a safe method for disposing of these waste materials. State and local regulations vary and dictate whether blood or other body fluids require pretreatment or if they can be discharged into the sanitary sewer and in what volume. (1)

It should be noted that the CDC does not recommend flushing blood soaked gauze down the toilet. OSAP does not recommend flushing blood soaked gauze down the toilet either. For example, there may be plumbing issues as gauze is not designed to break down and disintegrate quickly, such as toilet paper does.

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. (2)

Regulated waste shall be placed in containers which are:

1910.1030(d)(4)(iii)(B)(1)(i) Closable; (2)

1910.1030(d)(4)(iii)(B)(1)(ii) Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping; (2)

1910.1030(d)(4)(iii)(B)(1)(iii) Labeled or color-coded in accordance with paragraph (g)(1)(i) this standard; and (2)

1910.1030(d)(4)(iii)(B)(1)(iv) Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping. (2)

1910.1030(d)(4)(iii)(B)(2) If outside contamination of the regulated waste container occurs, it shall be placed in a second container. The second container shall be (2)

1910.1030(d)(4)(iii)(B)(2)(i) Closable; (2)

1910.1030(d)(4)(iii)(B)(2)(ii) Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping; (2)

1910.1030(d)(4)(iii)(B)(2)(iii) Labeled or color-coded in accordance with paragraph (g)(1)(i) of this standard; and (2)

1910.1030(d)(4)(iii)(B)(2)(iv) Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping. (2)

1910.1030(d)(4)(iii)(C) 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. (2)

According to the authors of Infection Control & Management of Hazardous Materials for the Dental Team, regulated waste is infectious medical waste that requires special handling, neutralization, and disposal. Two basic types of waste in the dental office are regulated medical waste and non-regulated medical waste. (3)

Many areas allow in-house neutralization of such items. The easiest and most effective procedure is sterilization by heat. Steam autoclaving is the method of choice. However, published information indicates that an unsaturated chemical vapor sterilizer is effective in neutralizing pathologic waste. One should never use dry heat ovens. (3)

Offices and clinics should be discreet about the final disposal of treated infectious medical waste. Reports indicate that waste haulers have refused to empty dumpster boxes or garbage cans if blood and blood soiled items are visible. The authors indicate that the best option probably is to place treated items into some type of sealed container, such as a cardboard box, before disposal. (3) 1) CDC's Infection Control Guidelines for Dental Healthcare Settings
2) OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030
3) Infection Control & Management of Hazardous Materials for the Dental Team, 3rd edition, by Miller and Palenik. Elsevier/Mosby Publisher. Copyright 2005.

How should we dispose of syringes that do not have needles attached?

In most states, if a syringe does not contain a sharp or fluid blood (such as those used for irrigation), there is no need to discard it in a medical or biohazard container; it is simply discarded with the regular office waste. To ensure compliance, however, always consult your state and local regulations.