YOUR DENTAL UNIT WATERLINES AND AMALGAM SEPARATION-WHAT YOU SHOULD KNOW

Waterlines 

     To deliver water of optimal microbiologic quality, dental unit waterlines must be maintained regularly. Colonization of microorganisms within the waterlines may not pose a concern for healthy individuals, but it may place elderly or immune-compromised patients at unnecessary risk. Although infection associated with microbial contamination of waterlines appears to be rare, dental unit waterlines have been shown to harbor a wide variety of microorganisms including bacteria, fungi, and protozoans in numbers sufficient to cause illness. These microorganisms colonize and replicate on the interior surfaces of the waterline tubing forming biofilms. Biofilms can serve as a reservoir, amplifying the numbers of free-floating microorganisms in the water.

     The Centers for Disease Control and Prevention (CDC) recommends that dental unit water used in nonsurgical procedures measure ≤500 CFU/ml. This is the standard set for drinking water by the Environmental Protection Agency (EPA). To deliver water of this quality, dental unit waterline systems designed for general dental practice must be regularly maintained, via water treatment and monitoring, performed according to the manufacturer’s instructions.

     While they will not eliminate biofilms, there are several methods for improving dental unit water quality.  However, practitioners should always consult with the manufacturer of their dental units before initiating any waterline treatment protocol.

1. Follow current OSAP, ADA, and CDC recommendations to flush lines for several minutes each morning. Flush handpieces with air/water for 20 to 30 seconds between patient appointments. Installing sterilized handpieces and sterile or disposable syringe tips after flushing will reduce cross-contamination.

2. Always obtain and follow the dental unit manufacturer’s recommendations for treating dental unit waterlines. Implementing protocols not recommended by the unit manufacturer could cause equipment damage and void warranties.

3. If recommended by the dental unit manufacturer, install and maintain anti- retraction valves to prevent oral fluids from being drawn into dental waterlines.

4. Avoid heating dental unit water. While it was common to heat water to increase patient comfort, warming the water may amplify biofilm formation and select organisms pre-adapted to growth in a human host.

5. Consider using a separate water reservoir system to eliminate the inflow of municipal water into the dental unit. In addition to having better control over the quality of the source water used in patient care, it would eliminate interruptions in dental care when “boil-water” notices are issued by local health authorities. Contact the manufacturer of the dental unit for a compatible system and treatment protocols before undertaking this step.

6. Use sterile solutions for all surgical irrigations. Additionally, ensure that only heat-sterilized/sterile-disposable bulb syringes or sterile water delivery devices are employed to deliver the sterile water.

7. Educate and train oral healthcare workers on effective treatment measures to ensure compliance and minimize risks to equipment and personnel.

8. Monitor scientific and technological developments in this area to identify improved technical approaches as they become available.

9. Cooperate with the oral healthcare industry to develop and validate standard protocols for maintaining and monitoring dental unit waterlines.

10. Because insufficient data currently exist to establish the effectiveness of all available methods as used in the dental office, it is important to ensure that any sterile water system or device marketed to improve dental water quality has been cleared for market by the U.S. Food and Drug Administration (FDA). 

11.  Staff compliance with whatever water treatment approach is chosen by the dental practice is very important. Staff input as to the choice and maintenance is crucial for any success achieved.

AMALGAM SEPARATION

     Amalgam separators remove amalgam particles from the wastewater to reduce the amount of amalgam entering the sewage system.  Amalgam separators are devices designed to capture amalgam particles from dental office wastewater through sedimentation, filtration, centrifugation, or a combination of these mechanisms. Some separators may also use ion exchange technology to remove mercury from wastewater. Whenever there is need for plumbing work or other activities that might dislodge amalgam waste adhering to the inside of the pipes, it is recommended that steps be taken to minimize potential health or environmental issues.

      Water with dental waste flows through the vacuum line and passes through the amalgam separator where teeth fragments, dental amalgam and mercury are separated and collected. The filtered water continues to flow through while heavy waste and sediment is stored.

     The Environmental Protection Agency’s (EPA) final rule on amalgam separators was effective as of July 14, 2017, however the date for compliance is July 14, 2020. While one could argue that research shows that dentistry is responsible for less than 1% of the mercury released into the environment, the ADA is supporting this effort and encouraging dentists to follow best practices for amalgam waste handling and disposal. In 2009, the Association amended its best management practices to include the use of amalgam separators that comply with ANSI/ADA Standard 108 for Amalgam Separators, which takes into consideration the standards developed by the International Organization for Standardization, a worldwide federation of national standards bodies.

     American National Standards Institute/American Dental Association (ANSI/ADA) Standard No. 109 defines amalgam waste as including amalgam (scrap), chair-side trap filters containing amalgam vacuum pump filters containing, amalgam, saliva ejectors if used in dental procedures involving amalgam, used amalgam capsules, extracted teeth with amalgam restorations, and waste items that are contaminated with amalgam. Dental best management practices for amalgam waste handling and disposal include use of chair-side traps, use of amalgam separators, regular inspection and cleaning of traps, and use of appropriate commercial waste service to recycle and/or dispose of collected amalgam. Compliance with the EPA final rule on amalgam separators is required.

DO:

1. use precapsulated alloys and stock a variety of capsule sizes
2.  recycle used disposable amalgam capsules
3. salvage, store, and recycle non-contact (scrap) amalgam
4. salvage (contact) amalgam pieces from restorations after removal and recycle their contents
5. use chair-side traps, vacuum pump filters, and amalgam separators to retain amalgam and recycle their contents
6. recycle teeth that contain amalgam restorations (Note: Ask your recycler whether extracted teeth with amalgam restorations require disinfection)
7.  manage amalgam waste through recycling as much as possible
8. use line cleaners that minimize dissolution of amalgam

DON’T:

1. use bulk mercury
2. put used disposable amalgam capsules in biohazard containers
3.  put non-contact amalgam waste in biohazard containers, infectious waste containers (red bags), or regular garbage
4.  put contact amalgam waste in biohazard containers, infectious waste containers (red bags), or regular garbage
5. rinse devices containing amalgam over drains or sinks
6.  dispose of extracted teeth that contain amalgam restorations in biohazard containers, infectious waste containers (red bags), sharps containers, or regular garbage
7.  flush amalgam waste down the drain or toilet
8. use bleach or chlorine-containing cleaners to flush wastewater lines

Additional highlights of the rule include:

• Dentists who practice in oral pathology, oral and maxillofacial radiology, oral and maxillofacial surgery, orthodontics, periodontics, and prosthodontics are exempt from the rule.
• Dentists who do not place amalgam and only remove amalgam in unplanned or emergency situations (estimated at less than 5 percent of removals) are also exempt.
• Mobile dental units are exempt.
• Dentists who already have separators are grandfathered for 10 years.

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CREATING AN OFFICE CULTURE

   Imagine a workplace where they offer you free meals, free haircuts, free car washes, free dry cleaning and on-site health care in addition to your health insurance.  The gym is down the hall, and there are nap pods and bean bag chairs. Instead of an assigned cubicle you can sit (or stand) anywhere you want to work.  You can even design your own desk to fit your needs . You are made to feel welcome and important from the minute you walk in the door and you are encouraged to bring your dog to work.  They offer you educational seminars, they have parties and bring in special guests to entertain you. There is a game room, a basketball court and impromptu volley ball games.  It sounds too good to be true, don’t you think?  Okay, so we can’t all be Google, but we can certainly learn from them.  While the perks are amazing, there are a lot more reasons why they have been consistently on the Fortune 500’s best places to work.

      It is not just the freebies that has kept Google on Glassdoor’s annual “Best Places to Work” list.  The search giant has cultivated one of the best workplace cultures in the world. The perks given are derived from surveys and algorithms (Google’s modus operandi) created to determine ways to keep employees happy, but more importantly “in the workplace” where they can be most productive.  While it is unrealistic for us to provide all of these extras in our dental practices, the bottom line is that Google is sending their employees a distinct and important message that doesn’t cost a dime. What they are saying is,  “We value you”.

      According to the Corporate Leadership Council,  “Engaged and satisfied employees feel a profound connection to their company, and are driven to help their employers succeed.”  And, in addition to the obvious elements such as job duties, benefits and salary, culture is a major factor in how happy employees feel on the job.  By creating an atmosphere where people feel positive, purposeful and engaged, you are sending the same message as Google to your employees.  “ We value you”.

     The good news is that you can create this environment for your team. Here are a few ideas, inspired by other offices, to help you get started.  

Establish Core Values and Goals

     Having your team write a mission statement is a good way to begin this process.  By doing this, you will create a common purpose, an intended direction and a guideline for determining what is important and what is not.  It is crucial for you to share your goals with your team, answer questions, and give input.  However, allowing them to actually put it in words will give them ownership, make them accountable, and they are more likely to embrace the meaning and significance of these important core values

     Once their mission statement is written, it can become the blueprint for team meetings, enhance the day-to-day decision making process, and align their efforts to work together.   When employees are passionate about the values and mission (like organizing the world’s information at Google), they are dedicated to accomplishing the goal.  Meaningful work is an essential component for keeping your employees happy and fulfilled. This in turn will lead to increased productivity and lower turnover.

Celebrate Together

      Everyone loves a cake and candles on their birthday. But acknowledging milestones is not the only way to celebrate as a team.  Encouraging your team to bond outside of the workplace helps everyone to get to know each other on a more personal level, an opportunity that doesn’t always present itself during the day in a busy dental practice.  Group outings can be as simple as a monthly breakfast club, signing up for a volleyball team, or going out for happy hour once a month. You can even assign one or two team members to plan the activity each month, which will help ensure that the group activities are viewed as fun, not boss-mandated!

       It always feels good to give back to the community, and volunteering as a group is another way to strengthen connections between your team. Plus, it’s a great opportunity to do some networking and establish relationships with local businesses, as well as promote your practice as a socially conscious organization.  A charity walk or run is one way to get started—not only will this encourage a bit of friendly competition, it’s a great way to get some exercise, too! Adopting a family at the holidays, working on a Habitat for Humanity project, or allowing team members paid days off to volunteer at the charity of their choice are other great options.

Encourage a Growth Mindset

     People with a growth mindset believe that their skills and abilities can be developed through perseverance and hard work; whereas those with a fixed mindset think their abilities are determined by natural talent or intelligence.  One of the first business books that I read when I started my practice was “ The One Minute Manager” by Ken Blanchard and Spencer Johnson.   They advised you to “catch your employees doing something right.”   We are quick to criticize when someone does something wrong, but how often do we praise an employee for a job well done?    Complimenting the effort employees make or acknowledging how hard they are working helps them overcome failures. People with a growth mindset attribute failure to a lack of effort, not ability. Righting a wrong only requires more hard work.  

     Getting rid of a fixed mindset also makes it easier for people to admit their mistakes. The ways errors are perceived is changed. A mistake is no longer an attack on them individually. It is an opportunity to learn and grow.  A person with an open mindset is more open to feedback.  They will actually welcome your guidance and are more likely to tackle new challenges.  

Conclusion

     There is growing recognition of the fact among business leaders that a strong culture gives you a competitive edge.   Companies win not because of what they do, but because of how they do it.  And how they do it is determined by culture.

     For better or worse, your office culture rules your organization.  It is a financial and strategic topic. In fact, it is one of the most important things you can do to create a sustainable competitive advantage. And what’s more critical to your organization’s future survival and growth than that?

DENTAL FORECASTS

Greetings to all and welcome to my blog!  I am just getting started, but I am very excited to have you join me.  My goal is to take a look at what success in dentistry looks like today, and how we can continue to bring that into our future as practitioners, industry leaders, and educators.  I am committed to keeping this real.  Please let me know what you want, what you need, and who you want to hear from.  I welcome any insights that you may have.  Let’s keep the lines of communication open!  I appreciate you more than you know!

Thank-you for visiting!

Lisa