Biomedical and Dental Waste Management: An Essential Component of Asepsis in Dental Clinics

Hari Parkash, MDS; Anil Kohli, MDS; Sunil Chaudhary, MDS; and Kaveri Hallikeri, MDS
Dentistry India
Abstract Proper handling of biomedical and dental waste management materials is an essential responsibility for the dental profession. Following the rules set forth by the Biomedical Waste Management under the Environment (Protection) Act is mandatory in India. Not only is it vital for protecting the environment, but it also helps safeguard human health. The authors propose a simplified classification using the US Centers for Disease Control and Prevention guidelines. This system focuses on which materials can be hazardous, the importance of handling these materials, and the best practices for recycling and safe disposal. In a country of at least one billion people, healthcare is always a major concern. Health professionals have continually wres tled with financial and ethical issues of treatment and adequate hygiene pre- and posttreatment. While healthcare concerns, by themselves, are a costly affair, biomedical waste disposal is an equally if not morecost-sensitive issue. Medical waste is generated as a result of diagnosis, treatment, or immunization of patients, as well as associated biomedical research.1 Biomedical waste is produced not only in hospitals but also in research institutions, medical and dental educational institutions, clinics, and laboratories. As these institutions face severe financial constraints, the need to review programs to ensure cost-effectiveness is critical. 2,3 Generally, dentists in this society hold an enviable position in terms of both respect and financial status. As a profession, dentistry is at the echelon of service to society in promoting and enhancing oral health. Unfortunately, some of t he materials used in oral healthcare present potential challenges to the environment, and managing their disposal prudently is critical. Knowing the facts about waste management is essential for ensuring proper handling of hazardous wastes in dental clinic s.4

Principles of Bio-Safety
In principle, effective waste disposal is the method to minimize potentially harmful effects to the environment and public he alth. To ensure this, safe techniques for managing infectious materials in the working environment whe re they are being used or stored are necessary: a process known as containment. The purpose of containment is to prevent or reduce exposure of persons and the outside environment to potentially harmful waste. There are two basic forms of containment: primary, which stems at the source of hazardous waste; and secondary, which aims at protecting the environment. Primary containment involves the protection of personnel and the immediate environment from exposure to infectious waste. Suitable, up-to-date, and well-maintained equipment and the use of good aseptic techniques can provide appropriate protection. Timely vaccination is an important aspect that needs to be stressed as added protection for personnel. Secondary containment involves the protection of the environment external to the working area. This is a more complex issue and can be achieved only by pooling resources from outside the immediate working environment along with judicious clinical practice. 5

It is part of human behavior to ignore subtle war nings from the environment. It is also human temperament to try to rectify mistakes retrospectively. Human behavior is not always logical, and some health professionals may compromise on basic rules of safety, leading to serious biohazardous concerns. In India, as in other nations, issues of containment have been vehemently discussed. With an effort to control the indiscriminate disposal of biomedical waste, the Government of India has issued a notification on Biomedical Waste Management under the Environme nt (Protection) Act. The various State Governments have constituted Biomedical Waste Management Rules to provide a common facility for operators to collect, transport, treat, and dispose of the waste in accordance with these rules (Table 1). Healthcare ins titutions are required to segregate, disinfect, and dispose of their wastes in an environmentally responsible manner. 3,6 Take the green route is the motto of this century. The need of the hour is to develop products or byproducts that can be recycled. Thus, the preferred method of disposal for many consumer and industrial waste streams (paper, wood, plastic, metals , chemicals, etc) is recycling. In most industrial settings, including professions such as dentistry, most heavy metal s like elemental mercury and silver can be easily collected and recycled. If not to be recycled, these metals must be disposed of as hazardous waste.7 Dental clinics generate a number of biomedical wastes, including blood -soaked materials and human tissue. Dentists are encouraged to follow Best Management Practices when disposing hazardous wastes.8 The best disposal option prevents or minimizes the release of toxic substances to the environment from dental clinics. Following these procedures will manage or reduce the release of toxins to the environment. 7,9-13 Based on the type of waste, the authors propose a simplified classification using the US Centers for Disease Control and Prevention guidelines:

Nonanatomic Biomedical Wastes (waste from dental materials/equipment/disposables that appear to be medical waste)
y Mercury-containing: elemental mercury, scrap amalgam; y Silver-containing: spent X-ray fixer, undeveloped film; y Lead-containing: lead foil packets, lead aprons, broken thermometers, blood pressure gauges; y Chemical or pharmaceutical waste: chemicals, disinfectants, sterilizing agents, expired drugs, waste -bearing
cyto/genotoxic properties;

y Contaminated/uncontaminated sharps: syringes (with/without needles), broken glass, scalpels, specimen tubes,
slides.

Anatomic Biomedical Waste

y Pathologic waste: blood, blood products, bodily fluids and tissues; y Infectious waste: cultures, infectious agents, associated biologicals (eg, culture flasks, petri plates, specimens,
vaccines, wastes from the production of biologicals, chemicals, disinfectants, sterilizing agents);

y Miscellaneous: dental wastes including surgical drapes/absorbents, protective gloves, disposable laboratory coats or
masks, dental laboratory waste, specimen containers, dental unit waterline, surgical smoke. The World Banks Health Care Waste Management Guidance Note lists four steps to healthcare waste management: 1) segregation of waste products into various components that include reusable and disposable materials in appropriate containers for safe storage; 2) transportation to waste treatment and disposal sites; 3) treatment; and 4) final disposal.
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Proper healthcare waste management minimizes the risk of further contamination of the environment. The process begins by separating wastes into reusable/nonreusable, hazardous/nonhazardous components. Additional procedures include sharps management system, waste reduction, provisions for secure waste collection and transportation, and insta llation of safetreatment and disposal mechanisms. 15

Nonanatomic Biomedical Wastes

Mercury-Containing Wastes
Tooth restoration often forms the greater part of patient inflow to the dental clinic, and the material of choice is usually amalgam. Therefore, elemental mercury is one of the major waste products in the dental clinic, and its waste management is critically important. The amount of amalgam used must be limited to the smallest appropriate size for each restoration. Use of bulk elemental mercury should be eliminated, and any unused bulk elemental mercury must be recycled or removed as hazardous waste. It must never be discarded into the regular trash, with infectious waste (yellow bag), or down the drain. All amalgam waste must be recycled or hauled away as hazardous waste as directed by the recycler or hazardous waste disposal program. This usually means in covered, segregated, and clearly labeled airtight plastic containers. 4,16-19

Silver-Containing Wastes
Undeveloped film and used fixer solution are considered hazardous because of their high silver content. Silver used in fixer solutions is in the form of silver thiosulphate complexes, which are extremely stable and have very low dissociation constants. Waste water treatment processes convert the silver thiosulphate into mostly silver sulfide. Two suitable methods manage fixer waste: a) separation of used f ixers from depleted developers; b) use of a silver recovery unit for a practitioners developing system. Dentists can also use digital x-ray equipment, which eliminates the need for processing chemicals and the resulting waste. In addition, digital x-rays can reduce patient radiation exposure. 9

Lead-Containing Wastes
Because lead is a leachate, it can contaminate soil and groundwater from landfill sites. Lead foil packets and aprons should not be discarded in general trash. Unless they are recycled for the ir scrap metal content, they are considered hazardous waste, and therefore certified waste carriers should be used for transportation and disposal. Companies that recycle amalgam or fixer ma y also accept lead waste. 9

Chemicals, Disinfectants, and Sterilizing Agents

In the dental clinic, a number of chemicals for sterilization and disinfection are used. Before discharging any chemicals to the sewer system, waste should be treated for eventual re-use of water for drinking. For best management practice, personnel should read the manufacturers instructions for all chemicals used in the office. Some of these chemicals may explode if sewered in certain quantities. Others may damage the pipes gradually. If any chemical has a flashpoint below 61C, a pH 2.0, or 12.5, it is better to contact the municipal sewer department and ask if the quantity generated in the dental clinic can be safely disposed into the sewer. If so, the drain must be flushed well when disposing these m aterials. 20

Other Chemicals
Because they are flammable and could explode, alcohols, ethers, and peroxides must not be discarded down the drain. These products are deemed hazardous waste, and unused products should be disposed of through a hazardous waste transporter.

The label directions on the product container should be followed for proper handling and disposal of all used disinfectants a nd cleaners. Recycle the empty container through the proper channel or dispose of it in the trash. The waste management service provider should be contacted to dispose of unused or expired products. 21

Contaminated/Uncontaminated Sharps
Sharps should be collected in the containers provided by the biomedical waste carrier: they are usually red or orange, marked with the universal biohazard symbol, inflexible, and puncture-resistant, with a lid that cannot be removed once it has been closed. When the container is filled, a certified biomedical waste carrier should be contacted for disposal. 22 Sharps must be recapped and not be in the regular garbage (this could create a health and safety issue for both the neighborhood and garbage collectors). Other biomedical wastes or other hazardous wastes must not be included in the sharps container. To prevent injury, the sharps container must be kept in its puncture-proof container and not be overfilled (more than three-quarters full). Healthcare providers should be aware that injuries from contaminated sharps can facilitate disease transmission. Hepatitis B (HBV), hepatitis C, and human immunodeficiency virus are of primary concern. For example, even dried at room temperature, HBV remains infectious for 1 week, and there is a 1 -in-3 chance that a single stick could result in sero-conversion.5,14

Anatomic Biomedical Waste

Human tissue must not be discarded with the regular garbage. Human tissue must be separated from other wastes and collected in a yellow liner marked with the universal biohazard symbol. This waste should be stored in a secure and locked ar ea with Biomedical Waste Storage signage and the universal biohazard symbol. This area must be distinct from other rooms and remain at a cool temperature (below 4C). Once a certain amount has been collected, a biomedical waste carrier must be contacted for disposal.22 All biomedical waste containers must be clearly indicated by a color code and the universal biohazard symbol. It is extremely important to prevent biomedical waste from being included in normal garbage, which is often incinerated, producing environmental toxins. Dental professionals are responsible for the safe handling of these and other potentially hazardous waste materials.

Blood or Other Bodily Fluids Generated During Treatment

All containers with blood or saliva (suctioned fluids) can be inactivated ac cording to government regulatory norms or the contents can be safely discharged in limited quantities into the sewer through a utility sink or toilet. 23 However, state/local regulations may vary in requiring pretreatment before these wastes can be discharg ed into the sewer, or whether they can be disposed of in the sewer and in what quantities. General waste from dental practices or clinical laboratories is no longer considered infective in comparison with residential waste, based on findings observed on microbial load and diversity. Most items in dental offices can be treated as ordinary waste, including gloves, masks, gowns, lightly soiled gauze/cotton rolls, and items used to cover equipment. Also, it is not necessary or practical to treat all items that have contacted blood, exudates, or secretions as infectious waste, as they are not always infective. 24-26

Miscellaneous Waste
Nonanatomic Wastes
Blood-soaked materials must not be discarded with the regular garbage. They must be separated from other waste s, collected in yellow liner marked with the universal biohazard symbol, and stored for fewer than 4 days. For any longer, the material must be refrigerated (below 4C). This waste should be stored in a secure and locked area with signage indicating Biome dical Waste Storage and the universal biohazard symbol. This area must be distinct from other rooms and remain at a cool temperature (below 4C). Once a certain amount has been collected, a biomedical waste carrier must be contacted for disposal.
8

Dental Laboratory Waste

Waste generated in the dental laboratory (such as disposable trays or impression materials) may be considered general waste and treated accordingly. However, disposal of sharps (eg, burs, disposable blades, orthodontic wires) should be don e in puncture-resistant containers for necessary actions. 27 In India, it is mandatory that all biomedical wastes must be handled in accordance with the Guidelines of Biomedical Waste (Management and Handling) Rules 1998, which were amended in 2000. All was te generated in dental practice must be segregated into the appropriate categories and disposed of accordingly, and all healthcare workers have a duty to ensure that the necessary precautions are taken when disposing of healthcare waste. Protective clothin g (apron, gloves, eyewear, etc) should always be worn when handling waste. Also, hazardous waste should be carefully labeled, secured, stored safely, and ultimately disposed of in appropriately colored containers.

y Black bags are used for non-risk waste and can be transported to a landfill. y Red bags are used for disposing sharps, tubing, gloves, blood bags, plastic bottles, syringes, etc. y Yellow bags are used for waste with significant healthcare risk, such as human waste, cotton and gauze pieces,
extracted teeth, etc.

y Blue bags are used for blades, medicine vials/ampoules or glass bottles, etc. 28
All equipment used for sterilization and waste disposal must be serviced regularly and maintained diligently to ensure appropriate sterilization conditions. 1,3,8,15,29

Training in Infection Control and Biomedical Waste Management

All dental staff engaged in any aspect of patient care should be thoroughly trained for prevention of cross infection and cro ss contamination. Staff are more likely to follow an infectio n control program and exposure-control plan if they understand its rationale. Moreover, every dental clinic must take all steps to ensure that any and all waste is handled without adversely affecting human health and the environment. Training should be updated annually and appropriate records kept. The dentist should verify that all staff remain current with their immunizations. 21

Conclusion
With ever-increasing numbers of conservationists and ecologists trying to prevent contamination of the environment, d entistry as a medical profession can contribute in its own ways, through its daily practices. Ignoring the needs of effective waste

management only hastens the inevitable end. Lack of knowledge and the increased cost of waste management are some of the issues impeding responsible waste management. However, small steps in the dental clinics and practices are the beginning of maintaining asepsis and preventing wider contamination. Dentists have the power to create a cleaner, greener planet and a saf er environment for future generations.

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